Agenda and Papers for the - NHS West Kent CCG€¦ · • Director, Marnock Place Management...

Agenda and Papers for the

West Kent Primary Care Commissioning Committee

(convening virtually)

on

Tuesday 24th March, 2020 0930 - 1230

via

Teleconference

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Meeting of the Primary Care Commissioning Committee (Part 1 – PUBLIC) To be held on 24th March 2020 (0930 - 1230)

A G E N D A Chair is Alistair Smith

Time Agenda no.

Agenda Item Lead Required Action?

0930

1 Welcomes and Introductions

Chair

TO NOTE

2 Apologies for Absence TO NOTE

3 Quorum and Declaration of Interests - Register of Interests

TO NOTE Pages 4 - 6

0935

4 Minutes of the previous meeting held on 4th February 2020

Chair FOR APPROVAL Pages 7 - 16

5 Actions arising from the previous meeting held on 4th February 2020

Chair TO NOTE Page 17

0945 6 Matters arising (not covered on agenda)

All TO NOTE

0950 7 Risk Register Risk Register Review

Chair Ruth Wells

FOR DISCUSSION Pages 18 - 28

1010 8 Primary Care Reporting: • TIA Audit• Nursing and Quality Team Report

Ruth Wells Marcos Menager

FOR INFORMATION Pages 29 - 52 Pages 53 - 60

1020 9 Finance Report Martin Kayes FOR INFORMATION Pages 61 - 71

1030 10 Handover to successor committee Ruth Wells FOR DISCUSSION Pages 72 - 76

1100 11 GP Estates Strategy Priorities – Update

Alison Burchell FOR INFORMATION Pages 77 - 107

1115 12 Section 96 Kent and Medway Policy

Ruth Wells FOR INFORMATION Pages 108 - 137

1130 13 Primary Care Operational Group Terms of Reference


1140 14 2017-19 Local Incentive Scheme review and outcomes

Emeka Madueke FOR INFORMATION Pages 148 - 183

1200 15 Proposal:continuation of services from Loose branch surgery


1215 16 Cranbrook Practices: General Practice Premises Development – preferred site

Alison Burchell FOR INFORMATION Pages 197 - 202

1225 17 AoB Q&A from the public

All FOR DISCUSSION

1230 CLOSE

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Date of the next meeting (as previously circulated): • N/A – Implementation of Kent and Medway Integrated Commissioning System.

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John Allingham • Member of the Primary Care CommissioningCommittee (non-voting member)

Kent LMC x x Direct Ongoing Non-voting member of PCCC

Gail Arnold • Deputy Managing Director, DGS and Swale CCGs• Portfolio Lead for Primary Care and MedicinesManagement, M, N and WK CCGs

None N/A N/A N/A N/A N/A N/A N/A

Biju Aravind • Secondary Care Clinician on Governing Body• Member of the Primary Care CommissioningCommittee• Member of the Remuneration Committee

Consultant Surgeon, East Kent Hospitals University NHS Foundation Trust

x Direct None of the interests declared currently represent a conflict of interest with CCG business. Should any of these interests represent a conflict with the scheduled or likely business of a meeting, the individual concerned will bring this to the attention of the chair of the meeting. The chair of the meeting will then determine how this should be managed and may ask the individual to withdraw from the meeting or part of it. This decision will be recorded in the minutes of the meeting.

Caroline Becher • Independent Nurse on Governing Body• Member of the Quality Committee• Member of the Primary Care Commissioning Committee• Member of the Remuneration Committee• Member of the Clinical Cabinet

• Management and Nursing Freelance Consultant• Director, Marnock Place Management Company,Tunbridge Wells• Director, 3 St James Road Management Company,Tunbridge Wells• Member Royal College of Nursing• Trustee for the Scotts Project Trust (LearningDisabilities)• Independent Nurse, DGS and Swale CCGs

x x Direct Ongoing None of the interests declared currently represent a conflict of interest with CCG business. Should any of these interests represent a conflict with the scheduled or likely business of a meeting, the individual concerned will bring this to the attention of the chair of the meeting. The chair of the meeting will then determine how this should be managed and may ask the individual to withdraw from the meeting or part of it. This decision will be recorded in the minutes of the meeting.

Dr Nick Cheales • GP Governing Body Member• Clinical Lead for Planned Care• Member of the Primary Care Commissioning Committee• Member of the Clinical Cabinet

• GMS contract holder – GP Principal at Winterton Surgery, Westerham, Kent• Westerham Practice is a shareholder in West KentHealth Ltd, the GP Federation in west Kent

x x Direct Ongoing GP members of Governing Body and the Primary Care Commissioning Committee will be excluded from any decision-making in relation to primary care commissioning in which their practices may have an interest.

Andrew Hayes Member of the Primary Care Commissioning Committee (non-voting member)

Representative of Health Watch Kent Direct Ongoing Non-voting member of PCCC

Gerald Heddell • Lay Member on Governing Body for Patient and PublicInvolvement• Member of the Remuneration Committee• Member of the Audit Committee• Member of the Quality Committee• Member of the Primary Care Commissioning Committee• Member of the Clinical Cabinet

None N/A N/A N/A N/A N/A N/A N/A

Declared interestCurrent Position held within CCGName Action taken to mitigate riskType of interest Date of InterestIs the interest direct or indirect?

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Register of Interests (March 2020)

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Dr Tony Jones • GP Governing Body Member• Clinical Lead for Workforce Education• Member of the Primary Care Commissioning Committee

• GMS Contract Holder at the Vine Medical Centre• The Vine Medical Centre is a shareholder in WestKent Health Ltd, the GP Federation in west Kent• Clinical Director, Maidstone Central PCN• Chairman and Trustee of Crossline counselling service • Trustee, Kenward Trust drug & alcohol service• Trustee, Maidstone Hospital postgraduate centre• GP tutor & Associate Dean (Kent) KSS Deanery• Chair, West Kent Education Network

x x Direct Ongoing Should any of these interests represent a conflict with the scheduled or likely business of a meeting, the individual concerned will bring this to the attention of the chair of the meeting. The chair of the meeting will then determine how this should be managed and may ask the individual to withdraw from the meeting or part of it. This decision will be recorded in the minutes of the meeting.

GP members of Governing Body and the Primary Care Commissioning Committee will be excluded from any decision-making in relation to primary care commissioning in which their practices may have an interest.

Reg Middleton • WK CCG Chief Finance Officer• Interim Chief Finance Officer, DGS and Swale CCGs• Member of the Primary Care Commissioning Committee• Member of the Performance and Finance Committee• Member of the Clinical Cabinet

• Partner is employed by East Sussex Healthcare – with whom the CCG has a healthcare contract (partner isnot in a position of authority in terms of decision making)

x x Indirect Ongoing Should any of these interests represent a conflict with the scheduled or likely business of a meeting, the individual concerned will bring this to the attention of the chair of the meeting. The chair of the meeting will then determine how this should be managed and may ask the individual to withdraw from the meeting or part of it. This decision will be recorded in the minutes of the meeting.

Mike Parks Member of Primary Care Commissioning Committee (non-voting member)

Kent LMC Direct Ongoing Non-voting member of PCCC

Richard Segall Jones • Company Secretary• Member of the Primary Care Commissioning Committee

• Director, Cavendish Health Care Consultancy Limited (not currently trading)• Partner, Conducting Business• Shareholder, Tune Into Care Ltd. (trading arm of the charity Sing For Your Life)• Member of the Guy’s & St Thomas’ NHS Foundation Trust• From 01/09/17, School Governor at ClaremontPrimary School, Tunbridge Wells• Wife, Veronika Segall Jones:• is a lay member on NHS England South (South East)Area Team panels considering GPwSI accreditation orthe general regulation and performance managementof GPs, GDPs and optometrists;• is Pharmaceutical Services Regulation Committee LayRepresentative NHS England (South East);• is a Patient and Public Voice Representative for GPRevalidation & Appraisal for NHS England South (South East);• chairman of the Tunbridge Wells Over Fifties Forum.

x x Direct

Indirect

Ongoing None of the interests declared currently represent a conflict of interest with CCG business. Should any of these interests represent a conflict with the scheduled or likely business of a meeting, the individual concerned will bring this to the attention of the chair of the meeting. The chair of the meeting will then determine how this should be managed and may ask the individual to withdraw from the meeting or part of it. This decision will be recorded in the minutes of the meeting.

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Alistair Smith • Lay Member on Governing Body• Chair of the Primary Care Commissioning Committee• Chair of the Remuneration Committee• Member of the Audit Committee

• Lay member for Governance at South Kent Coast CCG (member of Governing Body)• Directorships:o HRSS (HR Specialist Services) Ltd (Reg Office 14Orchard Drive TN28 8SE)*o SCI La Guiraude – non healthcare sector (Reg office:31290 Beauteville France).

*Note; Spouse (Janine P Smith) is joint owner of HRSS Ltd

x x Direct

Indirect

Ongoing None of the interests declared currently represent a conflict of interest with CCG business. Should any of these interests represent a conflict with the scheduled or likely business of a meeting, the individual concerned will bring this to the attention of the chair of the meeting. The chair of the meeting will then determine how this should be managed and may ask the individual to withdraw from the meeting or part of it. This decision will be recorded in the minutes of the meeting.

Richard Woolerton Member of Primary Care Commissioning Committee (non-voting member)

NHS England Ongoing Non-voting member of PCCC

Adam Wickings • Deputy Managing Director, West Kent CCG• Member of the Primary Care Commissioning Committee• Member of the Performance and Finance Committee• Member of the Clinical Cabinet• Member of the Quality Committee

• NHS Non-Executive Director, Medway LIFT Co Board.This means technically a NED on 4 separate (associated) companies:• Medway Community Estates Limited• Medway FundCo Limited• Medway FundCo Two Limited• Medway FundCo ( Canterbury Street) Limited• Mental Health and Independent Sector Lead forMedway, DGS and Swale CCGs

x Direct Ongoing Should any of these interests represent a conflict with the scheduled or likely business of a meeting, the individual concerned will bring this to the attention of the chair of the meeting. The chair of the meeting will then determine how this should be managed and may ask the individual to withdraw from the meeting or part of it. This decision will be recorded in the minutes of the meeting.

Paula Wilkins • Chief Nurse, Medway, North and West Kent CCGs• Governing Body member• Member of the Quality Committee• Member of the Clinical Cabinet

• Member of the Royal College of Nursing• Trustee at Heart of Kent Hospice• Cousin is a partner at Trowers and Hamlin Solicitors.

x x Direct

Indirect

Ongoing Should any of these interests represent a conflict with the scheduled or likely business of a meeting, the individual concerned will bring this to the attention of the chair of the meeting. The chair of the meeting will then determine how this should be managed and may ask the individual to withdraw from the meeting or part of it. This decision will be recorded in the minutes of the meeting.

Link to declarations of interest checklist:https://www.england.nhs.uk/wp-content/uploads/2017/06/coi-annex-e.docx

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https://www.england.nhs.uk/wp-content/uploads/2017/06/coi-annex-e.docx

Primary Care Commissioning Committee (PCCC) PART 1 04/02/2020, 1400 - 1700

The Village Hotel, Maidstone

Present Organisation Role Alistair Smith (AS) West Kent CCG Chair PCCC and Governing Body

Member Gail Arnold (GA) Dartford, Gravesham and

Swanley CCG and Swale CCG Deputy Managing Director (DGS and Swale CCGs) and Portfolio Lead Primary Care and Medicines

Richard Segall Jones (RSJ) West Kent CCG Company Secretary Andrew Hayes (AH) Healthwatch Kent HWK Representative (non-voting) Caroline Becher (CB) West Kent CCG Independent Nurse Donna Clarke (DC) Kent Local Medical Committee LMC Representative (non-voting) Biju Aravind (BA) West Kent CCG Governing Body Independent Secondary

Care Consultant Dr Tony Jones (TJ) West Kent CCG GP Governing Body Member Attending Organisation Role Ruth Wells (RW) West Kent CCG Senior Primary Care Development

Manager Matt Freeman (MF) West Kent CCG Corporate Services Manager (minutes) Tracey Creaton (TC) West Kent CCG Deputy Chief Nurse Marcos Menager (MM) West Kent CCG Head of Primary Care Quality for West

Kent and Workforce Martin Kayes (MK) West Kent CCG Senior Finance Manager Priscilla Kankam (PK) West Kent CCG Head of Primary Care and Medicines

Optimisation Nigel Gumbleton (NG) West Kent CCG Prescribing Advisor Natalie Rennie (NR) West Kent CCG Primary Care Project Manager Emeka Madueke (EM) West Kent CCG Primary Care Project Manager

Apologies Organisation Role Dr Nick Cheales (NC) West Kent CCG GP Governing Body Member Paula Wilkins (PW) West Kent CCG Chief Nurse

Gerald Heddell (GH) West Kent CCG Lay Member, Patient and Public Engagement

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1 Welcome and introductions

2 Apologies for absence Apologies conveyed from:

- Gerald Heddell- Dr Cheales- Paula Wilkins (NB; TC attending)

3 Quorum and Declaration of Interests Meeting was confirmed as quorate and there were no additional declarations of interest.

It was noted that there would be GP voting restrictions with regard to the Improved Access and Medicines Optimisation Scheme items.

4 Minutes of the previous meeting 03/12/2020 Minutes were reviewed page by page with approval contingent on the following amendments:

- Page 4; CB was concerned regards the 3rd paragraph regards the Nursing and Quality section.Highlighted that her query focused on the methodology of collection.

- Page 5; CB highlighted a correction; continued investment in CPMS.

CB also sought clarification whether the corresponding actions relating to the nursing and quality report had been completed. TC confirmed that distribution via the membership bulletin was pending further discussion at the Serious Incidents Panel.

CB – queried whether actions completed (distribution via bulletin / briefing) – TC confirmed pending further discussion at SI panel. Distribution via bulletin confirmed.

5 Actions arising from the previous meeting 03/12/2020 Actions from the 03/12/2019 committee meeting were reviewed:

- RW confirmed that detail had been incorporated to address gaps in PCCC022. Action closed.- RW confirmed that Risk Register action (PCCC003) was ongoing.

6 Matters arising (not covered on agenda) No items were raised.

7 Risk Register RW led discussion and highlighted the following key points:

- PCCC03 & 08 were recommended for closure.- PCCC022, 030 & 031 were updated following December committee discussion.

Since the last committee meeting the risk register has been to the Audit Committee (AS was also present). The Audit Committee provided good feedback on the content and format of the risk register and conveyed that robust reporting was in place.

Following committee discussion both PCCC03 & 08 were agreed for closure, though it was acknowledged that the latter may reopen in the new K&M System.

In addition PCCC022 (Primary Care Strategy, e.g. strengthening of partnerships between single handed practices) was noted as having improved phrasing and PCCC030 gaps in controls and assurances were now addressed.

As part of further discussion of wider risk register it was noted that: - CB flagged that as the risk owner A. Brownless needs to address the gaps in controls present in

both PCCC033 and 025.

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- PCCC010; AS flagged that estates will need to be reviewed in light of total system (K&M PCSestate strategy pending) and this is pre-requisite to new considerations for new developments. RWrelayed that Alison Burchell already works beyond West Kent remit.

- PCCC028 (Improved Access); AS queried whether this risk is worth remaining on the register as theproject is up and running. RSJ relayed that content sits more within the Primary Care Networkstrategy, namely performance reporting.

- PCCC030; AS flagged need for consideration around what good looks like and correspondingcomment within the register. TJ flagged that recruitment continues by PCN’ and acknowledged thatthis is at a slower pace than anticipated. GA relayed that also need to acknowledge the demandsbeing made on PCN’ in their infancy and that further clarification is needed regards PCN remit. Inaddition GA noted that there are mitigations already in place such as support from the Primary Careteam and consideration of requests of additional support as and when appropriate. AS queriedwhether PCNs are clear on how they will be held to account (considering that they will be an integralpart of ICPs), to which DC highlighted that currently they are an enhanced service and that thiscould be emphasised if and when PCNs become legal entities.

It was also noted that the register needs to be updated to reflect PCQS sign up at 98%.

8 Primary Care Reporting a) Primary Care Operational Group report

RW led discussion and the report was taken as read. Key points were highlighted by RW. - Noted that there was a small decline in the overall level of allocations and that could be attributed to

two of the larger practices reopening lists. It was acknowledged that there were some areas such asTonbridge where all practices are now managing their lists.

- Rent reviews and ongoing frustration with the District Valuer. Though some progress has beenmade, with Primary Care and DV agreement critical cases have now been prioritised.

- Otford section96; the practice have engaged with all aspects of the plan with the support of theLMC.

Comments and queries were invited.

AH queried, with reference to page 37 (Tonbridge Medical Group premises), what impact the rent review will have if any (acknowledged the review was for 2018 and their present premises). RW confirmed that any difference will be reconciled.

With reference to both Tonbridge and Malling both having managed lists, TJ queried whether we know the percentage of West Kent practices which have managed lists and if so would it be possible to review causal factors beyond practice growth (such as recruitment issues and workload). RW and AS confirmed data is available from 2017/18, though there would need to be clarity on what would be next steps should trends be found. GA noted that such an exercise would also be constrained regarding the disclosure of information at a practice level and in conjunction with this she also noted that there needs to be more emphasis on discussions at PCN level (to help mitigate potential for domino effect of closure/s which would largely negate the benefits brought by list management due to the allocations process). GA highlighted that from experience GP partner resignation is a particularly acute factor often leading to list management / closure. TJ anticipated that patient demand (not growth) and rates of access are key drivers, further to this GA noted this is also likely to be compounded by acuity of illness.

AS queried how PCQS phase 2 and PCN DES 2 differ. DC relayed that the former held a greater focus on non GMS core business which is trying to equalise service offers in Primary Care settings (frequently benefiting secondary care activity levels). In regards to AS concerns regards perceptions that there are disparate workstreams which are being directed to PCNs, DC flagged that a resolution would be dependent on PCNs becoming an entity and K&M ICS implementation. In conjunction with the above discussion GA highlighted the PCQS is contracted at a practice level which is a further differentiator from PCN DES, though delivery could be done in partnership. This contractual model was deemed as a good fit for list

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based delivery (GMS/APMS). Further to this TJ felt that PCQS could be considered as new money, unlike DES.

b) Nursing and Quality Team ReportMM led discussion and took report as read, highlighting the two key areas, CQC update and information on FFT returns and acknowledged that there is a slight change to the prior committee report.

- CQC; there are 3 practices requiring improvement which the CCG are supporting them to ensureadherence to minimum standards.

- 2 practices have a pending formal rating, one of which is dependent on registration and the other isdependent on CQC setting timescale for inspection.

- Clarification was pending whether the CCG commissioned any services from the IndependentHealth provider.

- FFT; MM noted there has been slight improvement in the latest report. There is continued qualityteam work to improve reporting levels and comparison at STP level shows a positive contribution toSTP levels from WKCCG membership.

BA felt that the sharing of FFT returns and STP contribution would be beneficial to help improve overall returns from membership.

9 GP Forward View, Highlight Report RW led discussion and highlighted that just over a year ago there was a similar presentation to the board. The report was taken as read. Key points were highlighted to the board.

- Transformation Fund; made available to practices which targets some of the high impact changes(see page 58). The fund pre dates Primary Care Networks. RW confirmed that the respective fundscame from the CCG and were drawn from £3 per head funds. Relayed some examples of therespective projects which have had a positive impact, e.g. cluster pharmacists, frequent service userrole, GP online consultation roll out (though the latter was acknowledged not to be drawn fromtransformation funds).

o With reference to the first contact physiotherapist scheme, AS queried whether there is anydouble counting between transformation fund and the reference made in the ImprovedAccess paper. RW confirmed that there is no double counting and that reference madeacross the papers entails that practices are using the same resource differently.

- RW flagged the ratio of successful bids to those submitted and of the successful bids, 3 havehelped practices at risk in the Weald.

- GP resilience funding confirmed as being sourced from the STP and that there will be continuedavailability following ICS implementation as funds are linked to 5 year period of forward view.

Comments and queries were invited.

Following query from AS, RW will investigate whether there is any patient feedback from the Care Navigation project. Referencing prior Clinical Cabinet discussion, BA highlighted that data was limited beyond levels of signposting.

With reference to page 60, CB sought clarification regards the fourth bullet point and corresponding list of projects. Felt that further comment re standout performance would be beneficial to the committee. RW felt that in terms of practice engagement, Care Navigation has been a standout success and that aforementioned clinical roles have positively impacted both practice and patient.

In regards to the collection and collation of patient feedback, GA noted the difficulty in collecting patient feedback (in relation to the clinical pharmacy role and other associated role centring on preventative activities) and then looking at triangulating across other points of delivery to investigate outcomes, namely secondary care settings and whether role successfully prevented an admission.

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TJ noted the importance of the cultural change associated with some of the projects and that there is a lot of signposting which is not recorded. In conjunction with this he also highlighted the benefit to confidence building brought by the introduction of new clinical roles. In addition, TJ reported that within a recent W Education Network meeting where quality improvement (one of the high impact changes) was discussed, practices reported a feeling that they were empowered to innovate.

10 Stage 1 Premises Proposal – The Medical Centre Group (Northumberland) AS highlighted that both this item and the next formed part of the closed PCCC meeting in December due to the pre election period. A summary was provided to the committee and further information regards December committee discussion are contained within the embedded minutes extract.

- The proposal centred on a move from stage 1 to stage 2 and was within the context of previousaccommodation of Grove Park and the respective site limitations.

Extract from 03/12/19 minutes:

Due to the period of sensitivity in the lead up to the general election it was agreed that the proposal should be considered in the part 2 meeting; the proposal along with the decision of PCCC will be included in the part 1 papers for the February Committee meeting

AB led discussion. The Medical Centre Group is also known as Northumberland Court. The proposal relates to the Grove Green branch surgery. The report was taken as read and the following key points were highlighted:

- The premises development proposal supports the estates strategy.- The practice have stated their intention to grow.- Taken on 2000 patients recently (following previously supported merger) with no additional

premises.- Would like new premises (confirmed that they currently lease premises). Practice is at capacity and

has identified the need for new premises to support growth in the area and resolve existingpremises challenges.

- The intention is for a GP led and funded development.- Closest five housing developments entail an increase of ~1800 residents in next five years.

In addition, the Maidstone Borough Council Local Plan is being review; additional growth is expected borough wide (moving from ~880 to ~1230 houses built annually from 2022). AS concerned that there seems to be a substantial increase in GMS space. AB highlighted that it was estimated and would be considered in detail linked to current list and future growth. The two existing premises combined were under sized for the patient list size. AB highlighted that modular planning could be considered, minimising the occurrence of over-capacity.

CB sought clarification on page 63 and what the abbreviation LSOA means. AB confirmed that it refers to Lower Layer Super Output Area which means a ‘mini ward’.

TJ relayed a concern of the implications of the proposal to the Maidstone Central Hub, regarding the need for additional general practice building in the centre of Maidstone. AB confirmed that there are no implications when accounting for level of growth, the revised MBC Local Plan and the catchment area of the planned development.

The committee supported the Stage 1 proposal. The proposal along with the decision of PCCC will be included in the Part 1 papers for the PCCC meeting on 04/02/2020.

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11 Stage 2 Outline Business Case – Phoenix Medical Practice Prior discussion within closed December meeting was surmised as following a previous stage 2 discussion. Case centres on a single premise replacing two existing sites whilst retaining dispensing facilities. An Equality Impact Assessment has been signed off and is in conjunction with range of patient engagement, both of which provided assurances to the committee around potential concerns (e.g. patient transport).

Extract from 03/12/19: Note change in agenda order; committee discussed 5b) prior to this item.

Due to the period of sensitivity in the lead up to the general election it was agreed that the Outline Business Case (OBC) should be considered in the Part 2 Meeting; the OBC along with the decision of PCCC will be included in the Part 1 papers for the PCCC meeting on the 4th February.

AB led discussion and took report as read. Noted a correction to the date on the front sheet; stage 1 premises proposal was supported by PCCC during October 2018 (not June).

AB provided the context and highlighted some key points regards the Outline Business Case. - Single premise which will replace two existing sites.- New premises are able to accommodate anticipated future growth- Noted there is a workforce plan required to mitigate impact of pending partner retirement. It was

noted that the new premises would be beneficial to recruitment.- Ability to retain dispensing is a core element of the practice business plan. This is subject to an

application for relocation being submitted and approved by NHS England.- The Equality Impact Assessment (included within pack) which has been signed off by EIA Lead.- Practice anticipate that as part of the dispensary element of the service there will be an expansion

to the delivery element which will utilise existing services in the locality.

AB invited questions from members.

It was noted that there were two engagement events held last week. The practice had provided the following headlines regarding key points raised:

- Transportation to the new surgery; local Councillors provided information regards the upgraded busservice that is being rolled out. In addition it was suggested that the existing volunteer car service inBurham could be expanded to all three villages (this would need to be explored locally).

- Parking at Peters Village; Trenport had confirmed to the practice that in addition to the dedicatedparking at the surgery there would be free (2 hours) parking in the area for shops/community hall.

- The challenge of working across two sites and the benefits a single site would bring werediscussed.

- Medication/dispensary and support for elderly and chronically ill patients; practice will be seeking toexplore how an existing church run collection service might be expanded. The practice is alsoexploring the potential of creating their own delivery service.

GH queried whether the engagement events were well attended to which AB relayed that the practice had advised that the first event was very busy and at the second event there were an estimated 20-30 people throughout the period of the open session.

BA flagged a correction to the EIA template on page 38. The pregnancy rate figures were incorrect and likely to be approximately half the given figure.

In response to workforce planning queries, AB confirmed that the practice has detailed the need for a workforce plan and would be moving this forward; advice / support would be provided as required. The practice has discussed their plans with the PCN Clinical Director.

On review of the floor plan, AH flagged that there is no open access to the dispensary section. AB confirmed that unlike the inclusion of a pharmacy, the dispensary did not require external access.

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In regards to the details of lease agreement, NC queried what would happen if one of the signatories left the left. AB confirmed that due to the minimum number of signatories and this would need to be maintained. The Workforce plan was important in this respect. AB highlighted that as with most leases there is an assignment clause that allows the lease to be assigned to another practice / NHS body should a contract no longer be held.

The committee supported the Stage 2 outline business case. The business case and decision of PCCC will be included in the Part 1 papers for the PCCC meeting on the 4th February 2020

It was noted that there was a pending correction within the pack; the decision for the committee to support the case was made in December 2019 and not 2020.

12 GP Online Consultation Project RW provided a verbal update to the committee highlighted that the procurement was completed late 2019 and that corresponding due-diligence has been completed. The winning supplier was Doctor Link and following further negotiation, contracts have been signed. Noted that this is a left footprint project and that the right footprint have selected a different platform (e-Consult).

A range of development is underway with Doctor Link including NHS App integration (20/21) and engagement with patients with Long Term Conditions to assist with QoF. Currently working with 6 practices in left footprint for PCN level implementation during the pilot phase. Contractually video consultation needs to be offered by next year.

AS sought clarification whether there is system compatibility between East and West. RW confirmed that there is not system compatibility, however there is scope to scale up one platform within contractual arrangements (e.g. 1+1+1 year). Noted that E Consult functionality can be delivered by Doctor Link.

13 PCQS Phase 2 – PSA Follow Up in Primary Care GA led discussion. The PSA Follow up scheme adds another service to PCQS bundle (which was confirmed as having 98% sign up from WK practices). It is the first of three additional services which as part of PCQS aims to help build consistency prior to merge into a Kent and Medway CCG. The service is for those with postrate cancer who are at stage where there are less frequent follow up requirements and therefore the patient is judged by consultant(s) to be at an appropriate stage to be managed within primary care. Secondary care Consultants will set parameters for GP monitoring and establish a clear range for which GP will escalate to consultants if exceeded. It is anticipated there will be a net overall saving for K&M system (using an invest to save approach). Allowances have been made for collaboration in delivery.

Comments were invited from the committee.

GA confirmed that there would be universal adoption of this service across the CCG membership and if there is an area which doesn’t have this service the CCG would have to look at alternative arrangements to ensure continued accessibility.

CB welcomed this service and appreciated the inclusion of the algorithm within the paper.

As a secondary care bowel surgeon, BA welcomed the scheme which afforded provision of follow ups which can be of a repetitive nature, within a far more convenient location than an acute environment. Noted that part of stratified pathway in East Kent is for the patient to take greater responsibility and not the GP. Also emphasised the importance of making sure that the pathway is absolutely clear and relayed that he is aware of software limitations which could otherwise be used to issue notifications and reminders. Though GA and RW did confirm that with correct coding there may be opportunities to mitigate software limitations, though they did acknowledge there will not be a central repository unless returns are at practice and hospital level (TJ drew comparison with DMARDS).

BA felt that there was a need to emphasise this service as a Patient Initiated pathway.

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Committee approved. It was also noted as comments around pathways was outside the remit of the PCCC NR will feed clinical comments to clinical working group.

14 Improved Access a) Wastage and slot utilisation

PK flagged that as team are continuing to work with the respective provider there is no respective paper however a verbal update was offered. PK highlighted some key points.

- Prior information has shown that there is 30% wastage, which may be a result of practice dataquality and incorrect use of software / associated process (e.g. not employing Vision 360). ThePrimary Care team working with software provider to mitigate.

- Noted that in last 6 months, uptake for other health care professionals has been improving.- Alongside Vision 360, the primary care team has also working with West Kent Health.

EM highlighted that Sevenoaks, The Ridge and Malling have a preference to use EMIS which is an alternative to Vision. Though AS commented that this is not reflected in slot utilisation as some of the practices within these PCNs show good levels of utilisation.

AS emphasised that these lessons learnt really need to demonstrated and incorporated into a contract extension following this pilot.

GA acknowledged that utilisation and data quality issues are a clear indication that further work is required to identify trends which are apparent during the pilot period. These issues are now forming part of the discussions with provider, which will continue into the requested extension. Acknowledged that an understanding and resolution where practicable are pre-requisite to procurement.

PK confirmed that assurance requirements (e.g. data quality) can have respective deadlines set within the extension.

b) Contract ExtensionPK led discussion and highlighted that they are exploring opportunities of extending the contract without issuing a PIN as we are working to a tight timescale. However it was acknowledged that the CCG did not have the risk appetite for this approach in conjunction with clear procurement advice which was not conducive to this approach. Both AH and AS emphasised the importance of following procurement advice and using committee mechanisms (e.g. virtual discussion and approval) to mitigate the risk of further lengthening timescale.

Committee agreed that a further option needs to be developed and presented to the Exec committee before coming back to the PCCC for approval.

15 2020/21 Kent and Medway Medicines Optimisation Scheme NG led discussion and highlighted that as part of the Kent and Medway merger the Medicines Optimisation Scheme was identified for consolidation and as such a working group was established with corresponding Medicines Management and LMC representation.

Comparison across K&M demonstrated that there was variation in costs and following discussion £1.50 was identified as a fair tariff. NG relayed that the MOS is comprised of 4 key areas:

- National priorities; respiratory, cardiology and diabetes.- Quality Improvement; following on from Quality Outcomes Framework and extending on from other

prescribing areas.- IT; with reference to the long term plan where IT software is used to improve prescribing

effectiveness and safety (Eclipse, Pincer and Script Search). There is the driver to developuniformity in software utilisation across peers.

- Cost pressure; whereby practices above CCG average are required to reduce by 4% (payment on

Page 14 of 202

sliding scale) and those below the CCG average maintain that level (with 1% growth leeway).

On behalf of the LMC, DC confirmed their full support of the MOS.

AS queried whether in light of variation across peers, does a single solution make sense, i.e. levelling up renumeration and levelling down ambition? NG flagged key importance is to develop common focus across peers which benefit national priorities, though there is still scope of individuals CCG to develop a local project(s).

PK confirmed that whilst the MOS has a Primary Care focus, there is independent work in secondary care settings around optimisation. GA also reiterated that local aspirations are not limited by this MOS.

RSJ sought clarification to three queries - Is it foreseen that QIPP responsibility is delegated to ICP in future? GA confirmed that this is the

likely direction, however the timescale will be greater than a couple of years.- Is there scope for greater savings (quality and financial) to be achieved; referenced page 169 and

the corresponding West Kent detail. PK confirmed that there are greater opportunities affordedthrough locally defined projects and pathways.

- Noted that an EIA is not necessary according to the front sheet. PK confirmed this has not been aprevious requirement as there is access to all registered patients. However AS flagged that as avoluntary scheme an impact assessment does need to be given consideration.

Following query from CB, NG confirmed that the weighting of payments (60:40) were the result of a discussion amongst lead pharmacists. BA also sought clarification whether the scheme was an enabler for e-prescribing (within practices). PK confirmed that a range of e-solutions are already in use and inherent indaily use, fulfilling both audit and identifier functions.

Committee indicated their support for the scheme. Approval would be needed from the single K&M CCG

16 Finance Report MK led discussion and took the report as read, taking the opportunity to flag some key points within the report:

- Change from last reported position resulting from the change to the weighted population sizecalculation which forms the basis of GP contracts. This singular revision to weighted populationformula equates to £240k drop in the payment for GP contracts.

- Overall position is 1% below plan- PCN spend is ~£310k below plan, which is attributed to role reimbursement and some

corresponding slippage (which could be carried over to 2020/21).- GPFV and STP; £1.2m of the latter is yet to be agreed and in regards to GPFV agreement is

pending for GP Fellowships and Aspiring Leavers.- A further net significant change which has been identified is a result of a change to the cost per

square metre costs.

MK highlighted that by 2023/4 the commissioner will need to identify saving of £2m and the both the risks of Quality Outcomes Framework achievement and Outstanding rent reviews could give rise to a ~£300k pressure.

Comments from the committee were invited.

RW flagged the morning STP/PCN meeting (04/02/20), in particular agreement to fund roles which support additional primary care capacity.

Page 15 of 202

17 a) Future PCCC/CPG operating processes and procedures

AS led discussion regards future committee configuration, highlighting there will be one single PCCC across K&M subject to a single Terms of Reference (which was presented to WK Governing Body last week). To date WK PCCC has successfully developed and set out policies and processes which form a decision making framework. It has been acknowledged that K&M scale strategies are yet to be developed, such as estates. It was noted that in conjunction with PCCC, each of the 5 Primary Care Operational Groups (one for WK) will have more delegated decision making to officers allowing some decisions to be made at an Integrated Commissioning Provider level.

GA relayed some of the longer term governance arrangements acknowledging whilst we currently have common delegated authority from NHS E, further common policies to be developed and that work has been underway at footprint level to achieve this.

Due to comparable advances within WK (in contrast to peers) there may be less apparent change. Also highlighted that PCOG Terms of Reference are under development.

The future timescale for PCCC meetings are monthly due to volume of business.

RSJ acknowledged that there are further considerations in regards to voting criteria. To date WK has allowed GP members to vote on set items, which in turn has then been disclosed to auditors. GA further clarified that in future GPs will not have voting capacity, though voting members need to account for GP views when casting vote(s).

TJ relayed a concern that it will be harder to develop premises going forward, given that K&M PCCC will be accommodating other CCGs operating deficit. GA could not confidently answer whether this would be the case, though she relayed that capital and revenue consequences of practice development and whether a practice would be willing to be contribute would be factors for support and approval of proposed cases. GA confirmed that as detailed in current strategy, Maidstone will remain as having a requirement for an additional practice.

GA anticipates that by March we will be able to share the PCOG terms of reference.

b) PCCC Terms of ReferenceIn conjunction with the discussion in the prior item there was further clarification that a GP member will be taken from each of the ICPs, alongside the Chief Financial Officer and Lay Members.

18) Forward PlannerAS emphasised that the focus for the additional March meeting is to ensure PCCC is ready for handover to the successor committee.

March items - Primary Care Operational Group Terms of Reference- Risk register review- Draft forward agenda

Note – there will be no Primary Care Operational Group report.

19) AoBNone raised.

CLOSE Next PCCC date –

• Tuesday 24th March, Hadlow Suite, Hadlow Manor Hotel NOTE THIS MEETING IS AT 9.30AM

Page 16 of 202

Agenda item Action Who When Updates Actions from 03/12/2019 7) Risk register PCCC003 – review how other CCGs have described risk

to build consistency and evidence targeted pieces of work

RW 04/02/2020 – confirmed as ongoing action.

Actions from 04/02/2020 4) Minutes of theprevious meeting

Confirm when SI lessons learnt material distributed via the membership bulletin

TC 02/03/2020 - Currently limited learning from SIs in primary care as there are so few reported. PMs rejected idea of newsletter, K&M Safety Team considering alternatives (e.g. quarterly briefing at PM meetings).

7) Risk register Escalate gaps in controls in PCCC033 & 025 to the risk owner to address prior to handover to the ICS.

RW and ABr

24/03/20

7) Risk register Close PCCC028 RW 7) Risk register Update IT risks before the March meeting ABr 13/03/20 8a) PCOG report Remove any information relating to closed cases, leaving

only live data in the report RW

8a) PCOG report Add zero line to allocations data (i.e. practices and localities which have no allocations)

Primary Care Team

8b) Nursing and Quality report

Seek further information from the CQC as members felt that Warders was previously inspected (DC confirmed that previously rated as good and that the website shows inspection as imminent and overdue).

MM

8b) Nursing and Quality report

Seek clarification whether any services are commissioning from the Independent Healthcare provider

MM

9) GPFV Establish what patient feedback has been collected in respect to the Care Navigation Project

RW, Dr Prince

15) Kent and MedwayMOS

Seek clarification on whether EIA is required for the MOS PK / NG

Page 17 of 202

Date: 24/03/2020 Reporting Officer: Ruth Wells Agenda Item: 7 Lead Director: Gail Arnold Version: 1.0 Report Summary: As part of the governance processes for the effective operation of West Kent Clinical Commissioning Group, a risk register is required for all major areas of the business. The PCCC is asked to review and update the PCCC risk register in light of any significant changes that may have occurred since its last meeting and agree the PCCC risk register.

PCCC is asked to approve the following amendments to the risk register:

New Risks PCCC034 – late submission, not discussed at PCOG – IT issue with GP2GP transfer of electronic medical records between Practice IT systems

Recommended Closed Risks PCCC031 – All Practices have now signed up for PCQS

Updated Risks PCCC010 – Amendments to ‘Action Plan to Mitigate PCCC011 – Update to Key Controls in Place PCCC029 – Owner change to Ruth Wells – amendments made to Gaps in Control and Action Plan to mitigate

FOI status: This paper is disclosable under the FOI Act

Primary Care Commissioning Committee (PCCC) Risk Register

This paper is for: Discussion

Recommendation: To review and agree the updated PCCC Risk Register (Mar 2020)

For further information or for any enquiries relating to this report please contact: Gail Arnold [email protected] 03000 425158

Page 18 of 202

mailto:[email protected]

Strategic objectives links:

All

Board Assurance Framework links:

Risks registers underpin the board assurance framework and all major changes to risks are reviewed on a bi-monthly basis

Identified risks & risk management actions:

None

Resource implications: None Legal implications including equality and diversity assessment

The Policy Book for Primary Medical Services (https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2016/01/policy-book-pms.pdf aims to support a consistent and compliant approach to primary care commissioning across England. It is essential that any decisions relating to primary care confirm to this guide and other statutory regulations and standard operating procedures that are in force.

Equality and diversity assessment

Has an equality assessment been undertaken? ☐Not applicable - Gail Arnold/Priscilla Kankam

Management of Conflicts of Interest

N/A

Public and Patient Engagement/Impact on patient services

N/A

Report history: N/A

Appendices N/A

Next steps: Primary Care Operational Group (PCOG) to regularly review and update PCCC risk register.

Page 19 of 202

https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2016/01/policy-book-pms.pdf


NHS West Kent CCG Strategic Goals 2014‐19

Risk Ref

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Date ad

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An explanation of the potential risk.

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Initial Risk Key Controls in Place

Controls that are in place which mitigate the level of risk i.e. contracts, action plans, monitoring arrangements, consultations, meetings with key staff, training programmes, terms of reference etc.

Internal & External Assurances on ControlsEvidence that shows that the controls are working, for example an audit report, an inspection report, an independent review, national benchmarking, board reports, consultations, KPI reports, NHSLA assessments, service reviews, annual reports, SIC, review of strategies, incident reports etc.

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t Risk Gaps in Controls

Where key controls in place are not effective in mitigating the level of risk. This could be due to a number of factors such as non‐compliance with policies, insufficient resourcing, a shift in priorities, lack or monitoring or management.

Gaps in AssurancesWhere there is no evidence of assurance or where the assurance provided is limited or gives a negative view i.e. an adverse external report.

Action Plan to MitigateHow the gaps in controls and/or assurances are being managed and what measures are being introduced to affect this.

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Status Latest PCCOG/PCCC Update

09/03/20 Reviewed by ABu but no updateAmendments due to go to PCOG for review on 19th March 2020

2 4

Aliso

n Bu

rche

ll

09/03/20

20

09/03/20

20

Ope

n 2 6 *Forecasting revenue impactsrequires a level of information only available once schemes fully worked up (i.e. actualcosts of development and District Valuer assessment). Estimates are made and reviewed at appropriate points.*The number of premisesschemes the CCG can support within the primary care budget will be limited and further policies and prioritisation is likely to be required

*Enusre full utilisation of existing estate supported by workforce plans

*Participate as part of first wave of national NHSE & NHSI led primary care estate data collection exercise in2020/21 to further inform and support local planning.

*Continue to work with other CCGs and partners (such as local authorities) to identify appropriate estates for services to be heldin/offered from.

*Continue to support practice andPCN level premises discussions regarding premises challenges and opportunities to ensure capacity exists to respond to growth.* Review and refresh of planning for growth priorities ‐ Update to March 2020 PCCC.* Primary Care budget forecast includes estimates for premises priorities.

2*Continuing to work closely with all four Local Councils to understand growth impacts of local plans currently in development and assess impacts on general practiceinfrastructure*GP Estates strategy (Nov 18) identifies premises priorities torespond to growth for each cluster area and informed by existing premises deficiencies (as per Premises Survey 2017); to bereviewed on an annual basis or in line with any local plan reviews.* Continued proactive engagement with individual practices andPCNs as determined through local plans and estates prioritiesalong with reactive support where required in response to specific issues.*Capacty for Primary Care Strategic planning increased* Premises Development Policy and operational processes in place to support robust management and review of propsals*Section 106 criteria and CIL funding policy approved by PCCC to support consistent process for applying and drawing down Section 106 funds from councils* Premises Development priorties in GP Estates Strategy used to inform forecasting revenue costs within the primary caredelegated budget.* WK Primary care premises developments and improvements detailed within the STP Estates Strategy.* Opportunities to seek capital funding through NHS routes willbe taken ‐ ie Improvement Grants, ETTF, STP

* Evidence that In line with the Premises Development Policy business cases are submitted to PCCC supporting priorties in the GP estates strategy *S106 funding being utilised to support premises improvement projects* Engagement in council local plandevelopment evidenced through general practice nfrastructure requirements detailed in local plans.*Evidence that opportunities are being taken to bid for capital funding (managed through the STP)

3Strategic Goal E: Sustainable finances

Sustainable finances1.To secure a sustainable financial future for theCCG and the Kent and Medway STP system2. To secure an appropriate balance between thecompeting demands and the NHS locally and the need to live within the budget allocated by Parliament3. To meet the CCG's financial duties whilemaintaining high quality clinical services4. To secure the maximum benefit per £ invested, in terms of health outcomes, and quality of care including by strengthening Aligned Incentives Contracts with major providers and through facilitation of collaborative approaches between members of the local health system5. To deploy resources in a way that secures the vision of the CCG in Mapping the Future, the FiveYear Forward View and the Kent and Medway STP towards shifting the provision of general care towards community based settings while maximising the benefits of funding in specialist care

PCCC

010

ESTA

TES AN

D PRE

MISES

01/03/20

17 There is a risk that without robust strategic planning opportunities for premises development will be missed and premises capacity may not be available to respond to population growth.

124 3Current TargetInitial

Current TargetInitial Current TargetInitial

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Current TargetInitialreviewed at PCOG on 25th Feb 2020

4 Sent for review to AB on 17/2/201 4

Andrew

Brownless

03/12/20

19

04/02/20

20

Ope

n 2 8

04/02/20

20

Ope

n

*Support offered to practices by system software providers. *Clinical systems moved to cloud based services *Vision offers guidance on daily actions practices should take to ensure effective business continuity including manual backups, tape cycles and restoring data. They also offer a disasterpreparation planning user guide and allow users to access clinical data offline.*Emis offers a business continuity mode which allows for alimited view of locally based version of patient data and when business continuity mode is activated it regularly checks for restored connectivity and will alert users if restored.*Servers stored off site for some practices within WKCCG.*Practices moving towards 'cloud based' storage facility for backup.‐*CCG commission CSU to provide IT to practices*Annual back up test by clinical system provider and CSU*CSU IT department conduct an annual visit and ask to see/review business continuity plan*CSU have developed a standard check list to improve the rigour and coverage of the annual visits,*Care Quality Commission (CQC) requires practices to developbusiness continuity plans. If a plan is not in place for thosepractices that have been inspected this will be highlighted in the post inspection report.*IT best standards checklist for inclusion in business continuityplans developed and presented to PCCC

*IT support offered to practices by CSU.*Support offered to practices by systemproviders.

*No mechanism to ensurepractices demonstrate to CCGthat adequate businesscontinuity plans are in place as they are not obliged to sharethem*Small number of practices have opted to retain onsiteservers hosting clinical systems, despite cloud based alternatives being available

*Capacity of practice staff to develop andcomplete business continuity plan

*Scrutinising CQC reports is essential and supported by the Quality team.*Chief Information Officer toscrutinise annual visit outcomes report provided by CSU at themonthly service review meetings, reports being made available to CCG via CSU customer portal*CCG and CSU to work with practices to demonstrate the benefits ofmoving to cloud based clinicalsystems

4

03/12/20

192 10

Dr Ton

y Jone

s/Ru

th W

ells*WKEN is supporting new roles through uniprofessional peer

learning sets. Currently 8‐10 paramedics, clinical pharmacists & advanced nurse practitioners are meeting on a regular basis, theyare recruiting others to their groups & to emploment in PCNsClinical pharmacists & social prescribing link workers have been employed by all PCNs & WKEN & WKH are collaborating over employment of physiotherapists for year 2 of new roles funding *WKEN delivered training, in line with the vision of the GPFV, to upskill existing practice staff to work along side GPs as Medical Assistants, supporting them with non patient facing responsibilities such as telephone triage and dealing with hospital letters. 30 20 practices have trained their staff using standardised protocols as developed during the training programme to enable that delegation of duties. Phase 2 training for established GPAs resulted in production of a workbook that can be used by practices wanting to develop the role

Next phase due in the Autumn once WKEN have sought to consolidate and learn from the early adopters

*Primary Care strategy ‐ STP workforce strategy ‐ West Kent workforce stategy ‐ Primary Care PCWG ‐ LEAB strategy*Workforce tool *Action plan ‐ initiatives ‐ 10 high impact changes*PCN's*NHS 10 year plan*First Contact Physio*New roles*Nurse Mentorship Programme*Practice Manager training Programme*New to Practice GP group*Networking Groups*Fellowship arrangement*Career Counselling

*Workforce tool report to Governing Body & PCCC*Bench marking*Strategic training update* Federation Quality Lead work on ANP supervision

5 3 15 * Increasing population growth beyond predicted or expected

*Increasing presssure ongeneral practice challenges their ability to respind to training needs

*Changes in priorities

*Vulnerable Practices*External factors*Primary Careworkforce lead

*Regular reports provided by WKEN will be discussed at PCOG and PCCC when necessary

*Learning from experience*Plan to recruit Primary Care workforce lead*PCQS bundle*Section 96 funding*Facilitated conversation with PCN's*GPFV*STP funding*HEE training and employment for hub

5

Strategic Goal G: Robust Organisational Competence PC

CC01

3

Strategic Goal D: Service quality and patient safety

Service quality and patient safety. Service providers commissioned, and performance managed, to promote and support the highest standards of care, clinical outcomes, patient safety and patient experience

PCCC

011

WORK

FORC

E

01/03/20

17 Failure of Primary Care to reform the new roles and high impact changes to address workload and workforce plan

5 3 15

BUSINESS CO

NTINUITY

20/03/20

17 Failure to have assurance that practices have robust IT Business continuity plans which could affect practices ability to operate as they are totally dependent upon IT. Practices need to ensure capability to operate when IT is not available. Plans need to cover server, network, system, power cut and N3 connection issues. If an issue affected a number of practices concurrently this would impact the CCG.

4 2 8

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Internal & External Assurances on Controls Evidence that shows that the controls are working, for example an audit report, an inspection report, an independent review, national benchmarking, board reports, consultations, KPI reports, NHSLA assessments, service reviews, annual reports, SIC, review of strategies, incident reports etc.

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Gaps in Assurances Where there is no evidence of assurance or where the assurance provided is limited or gives a negative view i.e. an adverse external report.

Action Plan to Mitigate How the gaps in controls and/or assurances are being managed and what measures are being introduced to affect this.

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Current TargetInitial*Lack of knowledge amongst practice staff around cyber security. * Not all practices have completed DSPT* NELCSU not currently accreditated against CE+

*Promote awareness amongst GP practice staff around cyber security. *Explore the possibility of using a cluster event to do this or an article in practice bulletin. *Learn lessons from Cybersecurity events such as the Wannacry attack in May 2017*Further IT continuity plans to be developed which focuses on safeguarding data: staff behaviour, robust processes and ensuring up to date security patches to ensure that local systems can receive and install respective updates*Local testing and confirmation required to ensure that back up processes are in place across practices particularly for practices on a managed server*Delivery of IG support services is reported to the CCG on a monthly basis via the K&M GP IT Strategy delivery group and service review meetings.*CSU providing a monthly assurance report to GP IT steering group which covers cyber security and provides assurance that patches are in place and have been updated*CSU GP IT facilitators to ask practices to register with CareCert so that they receive direct notification of practice specific issues*CCG Informatics team to continue to receive notification for unregistered practices and log these with the CSU service desk for resolution*CCG IT team to review IG toolkit to check relevant declarations and follow up when necessary*CSU IG team have identified and are working with those practices that did not complete DSPT* CE+ accredidation being built into NELCSU contract review with a target date of June 2021

2

03/12/20

19

04/02/20

20

Ope

n Sent for review to AB on 17/2/203 6

Andrew

Brownless2 4 8 Given the nature of

cybersecurity, this is an ongoing and evolving risk which requires constant focus and awareness of practice staff CCG visibility of the activities being undertaken by the CSU and the effectiveness of the activitiesNot all practices are registered on Carecert meaning that threat notifications are routed via the CCG


CC01

4

CYBE

R TH

REAT

20/03/20

17 Failure of practices to adequately manage cyber security threat. If there was a significant breach this could affect their ability to operate as they are totally dependent upon IT. If a number of practices were concurrently affected this would impact the CCG.

5 4 20 *Up‐to‐date software and hardware which are in warranty. *Up‐to‐date anti virus and cyber security packages. *All practice staff to undertake cyber security awareness training. *Practices need an IT business continuity plan in place.*NHS England have delegated responsibility for IG support to practices to CCGs, for West Kent, this is being executed under the LPF NELCSU contract, along with other primary care enabling services and the wider GP It support service. * IG toolkit completed by practices details whether cyber security training has taken place. IG toolkit is a self declared function*NHS Digital carecert service advises on threats and infections*Kent and Medway wide Primary Care DPO service established

*IT & IG support offered to practices by CSU.*Support offered to practices by system providers.

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Current TargetInitialStrategic Goal G: Robust

Organisational Competence PC

CC01

5

DAT

A QUAL

ITY

20/03/20

17 Failure of practices to manage correct entry of clinical data into the practice system resulting in the wrong or poor quality clinical data being entered which could result in patients receiving the wrong clinical treatment. This could also affect budget allocation received by WKCCG as disease coding may not to accurate and up‐to‐date.

4 4 16 2 8 *Capacity of CSU to offertraining to practice staff.

*Lack of knowledge amongst practice staff around use of thesystem.

*Obtain records from CSU of practice staff/practices that have undertakenrelevant training.*Explore the possibility of delivering cluster level training on this topic, facilitated by CSU.*Move from read coding to SNOMED CT provides the environment forimproving data quality as practices review coding and reporting procedures

*Correct set up of system. *Staff training offered by CSU on use of system. *Data quality audits. *CSU have produced a data quality guidance document for use by practices

*IT support offered to practices by CSU. *Support offered to practices by systemproviders.

4 Sent for review to AB on 17/2/202 4

Andrew

Brownless

03/12/20

19

04/02/20

20

Ope

n 2

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Current TargetInitial23*High level outline of IT solutions included in the primary care

strategy.*Federation, with support from the CCG CIO, has established anIT steering group.*IT is a standing item on the PCOG agenda*IT issues presented to PCCC as required

*Notes from Federation IT group*Approval of Federation business case for iPlato by PCCC in June 2017*Commissioning of Vision 360 solution to support GP federated working

*The CCG does not yet have in place a detailed, fully costed plan for implementation of the IT components to support theprimary care strategy.*The West Kent Federationdoes not yet have in place an ITStrategy*Limited federation IT resource and expertise

Sent for review to AB on 17/2/202 4

Andrew

Brownless

03/12/20

19

04/02/20

20

Ope

n 3 9 *Current national operating frameworkfor GP IT only runsuntil March 2018, no visibility yet of howthe operatingframework will evolve post April 2018*No independent assessment of outline IT plan.


CC01

9

IT SOLU

TIONS IN TRA

NSFORM

ATION

17/10/20

17 There is a risk that the primary care strategy will not be fully implemented because there is insufficient progress on the provision of IT solutions to support practices to transform service delivery and maintain high quality services.

4 4 16 *CCG, working with the NELCSU andthe Federation, to develop a more detailed strategic implementationplan to ensure that the necessary IT components are being planned for, funding may be required to do this.*CIO to work with the GP Federation to develop a IT strategy covering the evolving needs of the Federation.*Work with NHS England to gain insight and understanding future operating framework.*Consider commission independent review of high level plan as aprecursor to the development of the detailed plan.*Seek Federation sign off of the high level plan, via the Federation IT group*Logistical arrangements for federation IT group amended to gain greater federation engagement indigital issues* Action plan to be developed to resolve risks associated withelectronic referrals as well as trust failing to schedule adequate clinics and slots

* Localise the STP Digital primary care strategy, where necessary* Extract system inventory list fromthe NELCSU asset register as a precursor to rationalisation

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Current TargetInitial

Ope

n 3 12 *New Primary Care requires significant support from theFederation which is developing as an organisation still.*The bedrock of General Practice is under extreme pressure and there are a number of vulnerable Practices

*Federation LeadGroup outcomes are not fully reported.

*WK Whole system Local care deliveryboard established to overseeprogramme.*The CCG Primary Care Team still very much supports the Federation fully during its growth/transition to a staffed organisation.*The CCG Primary Care Team led by the Local Care Quality lead supportsall vulnerable Practices by developing a Quality Assurance and Quality Iniative Stategy to further improve how we recongnise and develop support packages for Practices/Clusters.*We will work with the Federation Lead Lead (Richard Estall) to improve how the Lead Group reports its out puts.

44 4

Ope

n All changes accepted at PCCC 4.2.20

PCCC

024

TRAN

SFORM

ATION

05/11/20

18 Failure to develop and embed new models of care including the transformation of primary care at the heart of local care

*The assurance that comes from local intelligence/knowledge is reliant upon thePC team maintaining good contact, good relationships

*Recognising the importance ofmaintaining dialogue/conversation and connection with Practices to allow for the time to be right*Recognising the importance ofalways knowing the current needs of the smaller Practices so that a network level bid can be sure to include them

3 2 6

Gail Arno

ld1. Our Primary Care Strategy focuses on developing a Primary Care model where Practices are of a resililance size, which mayinclude encouraging and/or supporting merges of smaller Practices 2. We have aligned our strategies eg estates so that we prioritise our investment towards practices that are larger3. PCN formation ensures that smaller practices are supported by a network4. We pay attention to horizon scanning for our smaller practices using tools/resources such as population maps and dataintelligence that supports us to identiy the single handed and vulnerable practices who may be at risk 5. We have established robust procedures and knowledge in the team to deal with a contract hand back 6. Effective team in place to ensure the management of GMS contracts and other non‐GMS contracts in place affecting primary care.7. Those who are vulnerable are aware how to access support8. Practices supported by visits with an open and transparent approach which encourages them to report pressure and problems early.9. the focus of the Primary Care team in building on strong relationships with Practices ensures that they know how to access support and funding

1. There is a demonstrable reduction in the number of practices from 61 to 55 *Independent Audit Report *Quality Team reports * Reports to PCOG & PCCC evidence the proactive reduction in single handers4. Local PC team intelligence/knowledge and relationships alongside the Practice Intelligence Reporting matrix and PCDashboards allows early detection of issues5. We have a policy that describes theapproach to a contract hand back situation so we can respond robustly and with a budget to support it *Cluster/PCN level meetings "Planning for Growth " held so that practices/clusters/PCNs are able to consider future developments, list growth, premises opportunities/challengesand make plans which can inluder mergers to protect single handers* There are now 6 single handers left

4 3

2 8

Ruth W

ells

03/12/20

19

04/02/20

2016 * General practice is the bedrock of primary care and is at the centre of Local Care * The Local Care plan is supported by this, the GPFV, the PCN's and the Federation * PCN's of practices are in development and in year one will focus on the recruitment of 2 new additional roles.* PCN's will be led by clinical director *GP Federation established with a board and employer status.Recruitment into key posts is complete.*Transformation Funding is fully deployed into a range of PCNbased transition projects/intiatives

*PCOG update report to PCCC. *Regular reporting to NHSE on development and progress on GPFYFV implementation ‐*Federation Led Lead Group (PM's & GP's) Fourm

4

03/12/20

19

04/02/20

2012 *Smaller Practices may resist merger.*Where investment funds are now aligned to network levelpopulations there is a risk for smaller Practices.*At any point a Practice mayelect to leave a PCN


CC02

2

PRAC

TICE

CONTR

ACT STAB

ILITY

29/01/20

18 1. The risk of single handed practices terminating GP contract

2. The risk of failing to adequately support any Practice

4 4 16

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Current TargetInitialSent for review to AB on 17/2/20

03/12/20

19

04/02/20

20

Ope

n 1 4

Andrew

Brownless

PCCC

025

06/11/20

18 As a consequence of the migration from the current N3 network to the new Health and Social Care Network (HSCN) service there is a risk that practices will lose N3 & internet connectivity, meaning that clinicalsystems and other remotely provided services will not be accessible

4 4 16 *Contract awarded to accredited HSCN provider*Development of high level design*Pilot phase to initiate rollout*Rollout to be phased to minimise disruption and to enable lessons to be learnt from pilot phase*Rollback window built into site migration plan*Detailed site migration plan developed*Rollout plan covering all practice sites has been completed

Oversight by NHS digital on HSCN providerHigh Level design signed off by NELCSU technical architects

4 2 8 Overall project plan to be developedK&M project team to develop detailed site migration planUpdate to be reported to PCOGContigency via KPSN to be explored

Contingency options to be explored ‐ KPSN, 4G, failover line

4

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As yet unestablished rhythmn and frequency of CD meetings with PC team Non compliance with the MOU Support not taken up PCN Plans not fulfilled

irregular and inconsistent flow of information from PCN's to Primary Care team

Establish regular purposeful meetings Nominate lead P C team member to be accountable for PCN, MOU and plan tracking and monitoringEstablish remedial support offer for failing/weakened PCNsHead of development and delivery to develop a targetted plan to address the gaps in control and assurances

44

03/12/20

19

04/02/20

20

Ope

n

All changes accepted at PCCC 4.2.20

1 4

Ruth W

ells

03/12/20

19

04/02/20

20

Ope

n 2 8

Amendments due to go to PCOG for review 19th March 20


PCCC

030

Prim

ary Ca

re Networks

11/07/20

19

PCN vulnerabilty due to lack of engagement from member practices

* As yet unestabished report format,schedule,responsibility

* The CCG recognises that some PCN's may need early and rapid intervention to meet the requirements* need to establish a monitoring and reporting framework

2 1 2

Prisc

illa Ka

nkam

Ruth Wells* PCN extended hours access plans submitted

* PCN extended hours access plans undergoing review and validation to ensure they are robust and meet the requirements* Triangulation of Practice, Out of Hours and Extended Hours data for monitoring* Regular monitoring of activity and reporting to NHSE/I

* Report to PCOG and PCCC* Reporting of the monitoring of activity data* Intelligent interpretation of activity data to allow for service review* National review of GP access under way.

3 3 9 * Some of the plan falls short of delivering against requirements * Data quality* All PCN delivery models in place and are inline with the PCN requirements.

4 3 12

1) PCN maturity index used as a tool to assess and monitor PCN vulnerability2) Tailored support and training offered to Vulnerable PCN's and CD's3) Robust agreement/ Schemes/ MOU's in place for PCN'shosting non DES practice population to mitigate any potentia risks.4)Network contract DES schedules5)STP level PCN development plan funding available for PCN's to develop year 1 local development support plans to ready themfor year 2

1) Regular updates on PCN maturity status to PCCC2) Regular meetings scheduled with Clinical Directors.3) reports and feedback from PCN meetings4) DES contract KPI monitoring 5)submission of PCN development plans for CCG's to review against an STP check list


PCCC

029

EXTE

NDED

ACC

ESS

22/05/20

19 Failure of the PCN's to deliver the requirements of the DESRisk of reputational damage

3 3 9

8 Need to get objective assessment on Vision position

Need to assess the impact that GP IT Futures has on the position

Continue to work with NHS Digital and NHS EnglandPlan approach to support the CCG obligations under the new GP IT Futures Framework (successor to GPSoC)

21. Practices only use GPSoC compliant systems2. Regular contact between CCG / CSU and the system provider3. Practices have right of choice over their principal clinicalsystems and can change, subject to agreeing business case with CCG

1. NHS Digital provide national oversight on national GPSoC framework and ensures that suppliers meet national expectations

4 2

03/12/20

19

04/02/20

20

Ope

n Sent for review to AB on 17/2/201 2

Andrew

Brownless

PRINCIPA

L CLINICAL

SYS

TEMS

12/03/20

19 As a consequence of losing national market share there is a risk that the Vision principal clinical system, which is used by over 20 practices in West Kent is not supportable or does not develop to meet practice's needs

4 2 8

PCCC

027

Target

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Assurance that GP IT Futures will cover all the existing and futures services that the CCG is obliged to make available to practices under the new operating model

1. All practices are using existing GPSoC compliant systems(principal clinical systems and subsidiary systems) and existing systems are expected to be on the new GP IT framework2. GP IT Futures framework will come in to operation from 1st January 2020 to replace the GPSoC framework which expires at midnight on 31st December 20193. Existing GPSoC contracts will roll over onto GP IT Futures framework, provided that they have been declared by the CCG to NHS Digital

NHS England have assured the CCG that GP IT Futures framework will be operational from 1st January 2020 and that all existing principal clinical systems and subsidary systems will be available on the new frameworkNELCSU have kept the tracking database upto date meaning that the identification of current principal clinical systems and subsidiary system is reasonably straight forward

4Strategic Goal G: Robust Organisational Competence

3 12 Lack of clarity about how the financial aspects of NHS Futures will workExpectation that CCGs will need to reprocure all GPSoC services under GP IT Futures within the first 12 months of the new framework

4 16

PCCC

033

GP IT Futures New risk added & agreed at PCCC

3/12/19Sent for review to AB on 17/2/20

1 2

Andrew

Brownless

03/12/20

19

04/02/20

20

Ope

n 2

23/01/20

20 New Risk ‐ to be reviewed at PCOG on 19th March 2020

1 1 2

Andrew

Brownless

Strategic Goal G: Robust Organisational Competence

13/11/20

19 As a consequence of the end of the GPSoC framework NHS England are creating a new procurment framework for GP IT systems known as GP IT Futures, the CCG has limited information on how this new framework will work and what the implications (financial and operational will be)

4

*The PCQS contract has been sent to all practices in west Kent.100% of practices have returned a signed contract.*Practices have to issue a minimum of six months’ notice to terminate their contract. This provides WKCCG sufficient time to explore an alternative solution for the affected practice population to ensure they still have access to PCQS services.

*Evidence of signed contracts;*Monthly invoice submissions and KPIreporting will actively evidence service delivery and service quality.

PCCC

032

Digita

l Clin

ical Safety

13/11/20

19 CCGs need to provide digital clinical safety advice to practices

under its obligations in Securing Excellence in Primary Care (GP) Digital Service

2 4 8 1. The CCG have commissioned NELCSU provide digital clinical safety advice through the GP IT contract2. Clincial advice is accessible through other CCGs

1. Digital clinical safety standard is defined nationally (DCB0160)2. Principal clinical systems are developed to meet the clincial risk management standard for the manufacture of health software (DCB0129) ‐ this is one of the mandatory obligations of GPSoC and GP IT Futures frameworks)3. Regular training courses are run by NHS Digital

2 2

2 8 The CCG does not have a trained clinican qho is qualified to provide digital clinical safety advice

As part of the CCG merger seek to build build digital clinical safety into the responsibilities of an appropriate, clinically registered, professional

*N/A *N/A

4 2 New risk added & agreed at PCCC 3/12/19Sent for review to AB on 17/2/20

1 2

Andrew

Brownless

03/12/20

1926

/02/20

20

04/02/20

20

Ope

n

04/02/20

20

Ope

n Task owner and PCOG recommend that this risk is now closed as 100% of WK practices have signed the PCQS Contract. Amendments due to go to PCOG for review on 19th March 20

2 1 3 NR2

*N/AStrategic Goal D: Service quality and patient safety

PCCC

031

Prim

ary Ca

re Qua

lity Stan

dard

18/07/20

19 General practice(s) may decline to sign the PCQS contract or withdraw at any time, resulting in inequitable access to services for the WK patient population.

4 3 12

20 1. All practices are using national approved clinical systems 2. Clinical system suppliers are working with NHS Digital to rectify this issue

CCG and CSU have escalated this issue to both NHS Digital (who manage the GP IT Futures framework and to NHS England.

3 5 12 Need to ensure that practices who are likely to receive large clincial records from Vision systems are aware of the issue

No "fix" date is visible at this point

Continue to escalate to NHS Digital and NHS England until the issue is resolved and a fix is in placePC

CC03

4

Digital C

linical Safety

23/01/20

20 There is a issue in the national GP2GP clinical record transfer process that moves the clinical record from one GP Practice system to another when a patient changes practice whereby large records are not transferred in full resulting in the receiving practice not having access to scanned letters. This issue only occurs where the sending practice is using the vision clinical system

4 5Strategic Goal G: Robust Organisational Competence

Page 28 of 202

Date: 05/03/2020 Reporting Officer: Ruth Wells Agenda Item: 8 Lead Director: Gail Arnold Version: 1.0 Report Summary:

Scope

The objective of this audit is to provide assurance on aspects of Primary Care Co-Commissioning as set out in NHS England’s August 2018 document ‘Primary Medical Care Commissioning and Contracting: Internal Audit Framework for delegated Clinical Commissioning Groups’. In 2019/20 it was agreed that the area of focus would be Contract Oversight and Management Functions

Overall Conclusion

• Monitoring Quality Safety and PerformanceIt was confirmed that the CCGs have adequate processes in place for monitoring general quality, safety and performance of GP practices and the management of practice opening times and extended hours access.

• Managing List Closures

Whilst it was confirmed that the CCGs have adequate processes in place for managing patient list closures, the CCGs processes for gaining assurance from Primary Care Services England regarding patient list maintenance could be improved.

Assurance Review of Delegated Commissioning Kent and Medway conducted by TIAA 2019/2020 issued February

2020

This paper is for: Information

Recommendation: This is the annual assurance review of delegated commissioning conducted by TIAA for the CCGs of Kent and Medway

It is for information purposes

For further information or for any enquiries relating to this report please contact: Ruth Wells, Primary Care Development Manager

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• Contract Reviews

Testing noted that the CCGs have undertaken contract reviews and were in the process of developing more proactive approaches to GP contract reviews. However, it was identified that there was not a rolling programme of deep dive contract reviews as required by the NHSE Primary Medical Care Policy and Guidance Manual.

• Management of poorly performing practices

The CCGs have adequate processes in place for the management of poorly performing GP practices and mergers. Processes for the management of practice closures could be further defined and improved.

Outcome The report identified 5 routine recommendations which are detailed in the report – the key domains are:

1. To develop common processes, policies and checklists2. To obtain assurance from PCSE around targeted list maintenance3. Develop a common list size tracker4. Introduce a rolling programme of deep dive practice reviews5. Development of a K & M wide dashboard for quality, safety and performance




(Provide guidance as to where members can cross-reference the information in this report)


Resource implications: Legal implications including equality and diversity assessment

N/A


N/A


N/A


N/A

Report history: West Kent PCOG 25 February 2020

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Appendices TIAA report

Next steps: For PCCC for information and for the recommendations to carry forward to the single ICS

Page 31 of 202

Internal Audit

FINAL

NHS Medway, North and West Kent Clinical Commissioning Groups

Assurance Review of Delegated Co-Commissioning

2019/20

Page 32 of 202

Executive Summary

OVERALL ASSURANCE ASSESSMENT OVERALL CONCLUSION

It was confirmed that the CCGs have adequate processes in place formonitoring general quality, safety and performance of GP practices andthe management of practice opening times and extended hours access.

Whilst it was confirmed that the CCGs have adequate processes inplace for managing patient list closures, the CCGs processes forgaining assurance from Primary Care Services England regardingpatient list maintenance could be improved.

Testing noted that the CCGs have undertaken contract reviews andwere in the process of developing more proactive approaches to GPcontract reviews. However, it was identified that there was not a rollingprogramme of deep dive contract reviews as required by the NHSEPrimary Medical Care Policy and Guidance Manual.

The CCGs have adequate processes in place for the management ofpoorly performing GP practices and mergers. Processes for themanagement of practice closures could be further defined andimproved.

SCOPE ACTION POINTS

The objective of this audit was to provide assurance on aspects of Primary Care Co-Commissioning as set out in NHS England’s August 2018 document ‘Primary Medical Care Commissioning and Contracting: Internal Audit Framework for delegated Clinical Commissioning Groups’. In 2019/20 it was agreed that the area of focus would be Contract Oversight and Management Functions.

Urgent Important Routine Operational

0 0 5 0

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Management Action Plan - Priority 1, 2 and 3 Recommendations

Rec. Risk Area Finding Recommendation Priority Management Comments

Implementation Timetable

(dd/mm/yy)

Responsible Officer

(Job Title)

1 Compliance West Kent CCG has developed a checklist / process document based on the Primary Medical Care Policy and Guidance Manual (PGM) around list closure applications. DGS and Swale CCGs use the same checklist / process document used by West Kent CCG. However, Medway CCG has not developed a checklist / process document and does not use the same document as the other three CCGs.

Ensure that consistent checklists are introduced, for example for planned and unexpected practice closures, in preparation for the merged Kent and Medway CCG, and in line with the Primary Medical Care Policy and Guidance Manual.

3 A single commissioner Primary Care work stream has been set up to align in common all local primary care policies, processes and procedures in line with the Primary Care Medical Guidance Manual and Policy.

Implemented (Subject to Internal

Audit review)

Heads of Primary Care Kent and Medway CCG

2 Compliance Primary Care Services England (PCSE) representatives regularly attend the Kent and Medway Primary Care Delegated Co-Commissioning network meetings to provide updates on their work, including targeted patient list maintenance. However, the CCGs have not sought nor gained clear assurance from PCSE of the extent of the work with practices completed by PCSE within the CCGs areas.

The CCGs to obtain assurance and understanding of the outcomes from Primary Care Services England (PCSE), in relation to the work undertaken on targeted patient list maintenance with practices within the CCGs areas.

3 A review of the current arrangements will take place with PCSE to inform the assurance process regarding targeted patient list maintenance.

30/04/20 Heads of Primary Care Kent and Medway CCG

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Rec. Risk Area Finding Recommendation Priority Management Comments

Implementation Timetable

(dd/mm/yy)

Responsible Officer

(Job Title)

3 Compliance It was noted that each of the CCGs use different practice list trackers, with different frequencies of monitoring changes to list sizes in place

In preparation for the merged Kent and Medway CCG, introduce a consistent practice list size tracker, with regular monitoring and reporting processes.

3 One single approach will be designed such that there is a consistent list size tracker with regular common monitoring and reporting processes.


4 Compliance It was identified that the CCGs have a risk based approach to reviewing contracts with GP practices which is driven by performance, quality and safety, as required by the PGM. However, it was noted that there is not a rolling programme of deep dive contract reviews as required by the PGM.

Introduce a rolling programme of deep dive contract reviews as required by the Primary Medical Care Policy and Guidance Manual.

3 One single K & M level programme for deep dive practice contract reviews will be developed in line with national guidance and good practice identified elsewhere in the country


5 Compliance The dashboards and tools used to gain assurance around the quality, safety and performance of GP practices could be further enhanced by inclusion of other soft intelligence gathered. It would also be beneficial to have all information and data gathered around a practice's performance, quality and safety, in one place / a central depository for each practice; for all relevant CCG team’s staff to refer to when working with practices during visits.

The practice dashboard and quality assurance tools used by the CCGs to include friends and family test and patient survey feedback results, together with other soft intelligence gathered about a practice, with a central system or depository to be developed in preparation for the one Kent and Medway CCG, to collate the information for each GP practice.

3 This work is already in progress in preparation for one single commissioner. It is being led by the Head of Quality for DGS CCG.

31/12/20 Head of Quality DGS CCG

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Operational Effectiveness Matters

Ref Risk Area Item Management Comments

No Operational Effectiveness Matters were identified.

Page 36 of 202

Detailed Findings Introduction 1. This review was carried out as part of the planned internal audit work for 2019/20. Based on the work carried out an assessment of the adequacy of the

arrangements to mitigate the key control risk areas is provided in the Executive Summary.

Background 2. This audit provides assurance on aspects of Primary Care Co-Commissioning as set out in NHS England’s August 2018 document ‘Primary Medical Care

Commissioning and Contracting: Internal Audit Framework for delegated Clinical Commissioning Groups’.

Materiality 3. The NHS England (NHSE) framework introduces specific new requirements to ensure primary medical care features in Clinical Commissioning Groups (CCGs)

annual Internal Audit plans. The framework also sets out the mandated scope of coverage for the work in four areas which are:

• Commissioning and Procurement of Services.

• Contract Oversight and Management Functions.

• Primary Care Finance.

• Governance.

4. It is required that the framework is delivered as a three to four year programme of work with all areas within the scope having been audited by March 2021.

Key Findings & Action Points 5. The key control and operational practice findings that need to be addressed in order to strengthen the control environment are set out in the Management Action

Plan. Recommendations for improvements should be assessed for their full impact before they are implemented.

Scope and Limitations of the Review 6. The objective of this audit was to provide assurance on aspects of Primary Care Co-Commissioning as set out in NHS England’s August 2018 document ‘Primary

Medical Care Commissioning and Contracting: Internal Audit Framework for delegated Clinical Commissioning Groups’. In 2019/20 the agreed focus was onContract Oversight and Management Functions.

7. In order to achieve the objective, the areas mandated by NHSE were considered, which related to the accessibility and quality of GP services were as follows:

• CCG management of GP Practice opening times and the appropriateness of sub contracted arrangements.

• Managing patient lists and registration issues (for example, list closures, targeted list maintenance, out of area registration, special allocationschemes).

Page 37 of 202

• CCG identification of practices selected for contract review to assure quality, safety and performance, and the quality of the subsequent review and implementation of outcomes.

• CCG decisions regarding management of poorly performing GP practices including contractual management decisions and liaison with the CQC where appropriate.

• Overall CCG management of GP practice mergers and closures (if applicable).

8. For the areas reviewed, the audit also reviewed progress made with the development of new structures and processes in preparation for the change to a single Commissioner from April 2020.

9. The approach taken was to evaluate the adequacy of the processes in place and to sample test key controls which included reviewing supporting documentation and the administrative processes. This included evaluating the adequacy and effectiveness of the processes in place within each of the CCGs (to inform best practice and consistency). The review was based on sample testing and did not cover all records.

Disclaimer 10. The matters raised in this report are only those that came to the attention of the auditor during the course of the internal audit review and are not necessarily a

comprehensive statement of all the weaknesses that exist or all the improvements that might be made. This report has been prepared solely for management's use and must not be recited or referred to in whole or in part to third parties without our prior written consent. No responsibility to any third party is accepted as the report has not been prepared, and is not intended, for any other purpose. TIAA neither owes nor accepts any duty of care to any other party who may receive this report and specifically disclaims any liability for loss, damage or expense of whatsoever nature, which is caused by their reliance on our report.

Risk Area Assurance Assessments 11. The definitions of the assurance assessments are:

Substantial Assurance There is a robust system of internal controls operating effectively to ensure that risks are managed and process objectives achieved.

Reasonable Assurance The system of internal controls is generally adequate and operating effectively but some improvements are required to ensure that risks are managed and process objectives achieved.

Limited Assurance The system of internal controls is generally inadequate or not operating effectively and significant improvements are required to ensure that risks are managed and process objectives achieved.

No Assurance There is a fundamental breakdown or absence of core internal controls requiring immediate action.

Acknowledgement 12. We would like to thank staff for their co-operation and assistance during the course of our work.

Page 38 of 202

Release of Report 13. The table below sets out the history of this report.

Date draft report issued: 3rd January 2020

Date management responses received:

Date final report issued:

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14. The following matters were identified in reviewing the Key Risk Control Objective:

Directed Risk: Failure to direct the process through approved policy & procedures.

14.1 Primary Medical Care Commissioning and Contracting: Internal Audit Framework for delegated Clinical Commissioning Groups was published by NHSE in August 2018. The document introduces specific new requirements to ensure that primary medical care features in Clinical Commissioning Groups (CCGs) annual Internal Audit plans. The document also sets out the mandated scope of coverage for the work in four areas including Contract Oversight and Management Functions.

14.2 Testing confirmed that the Medway, North and West Kent CCGs (MNWK CCGs) use and refer to the NHSE Primary Medical Care Policy and Guidance Manual (PGM) as updated in November 2017, and April 2019, to inform and guide the processes in place around the accessibility and quality of GP services. Where applicable and appropriate, the CCGs use the guidance to inform the management of the following areas:

• GP practice opening times.

• List closures and targeted list maintenance.

• Contract review to gain assurance of quality, safety and performance.

• Poorly performing GP practices including contractual management decisions.

• GP practice mergers and closures.

Compliance Risk: Failure to comply with approved policy and procedure leads to potential losses.

Managing GP Practice Core Opening Times

14.3 It can be confirmed that practices are required by NHSE to submit electronic self-declarations (e-decs) on an annual basis, which includes declarations regarding opening times, including the appropriateness of any subcontracting in place.

14.4 In addition to the annual NHSE process outlined above, the Primary Care Teams also carry out checks on practices, such as:

• Calling practices during opening times to verify if the practice is open. Checking if voicemail / recorded messages are used by practices and thatthe details and information given to patients is accurate regarding opening times.

• Checking practice websites for opening times advertised to patients.

• Drive by / in person spot checks of practices during the hours they should be open.

14.5 All of the information gathered through these checks is recorded on core contracting hour’s spreadsheets against each practice. The checks have been carried out on a rolling basis across all practices since April 2019.

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14.6 Therefore, it was confirmed that the CCGs, together with NHSE, have processes in place to review practice opening times annually and on a rolling basis, and to review whether any subcontracting arrangements in place are appropriate.

14.7 The checks completed since April 2019 and recorded on the core contracting hours spreadsheet, have assisted with identifying actions to be taken by any practices regarding opening hours, in order to ensure that the reasonable needs of patients are being met, in line with NHSE requirements regarding half day closures and the extended hours access Directed Enhanced Service (DES) payments. In addition, the CCGs also use soft intelligence from other sources, such as patients, to highlight any concerns regarding practices not being open and available for core contractual opening hours. It was advised that in the event that such reports were made to the CCGs, then this would be investigated with the practice for resolution.

14.8 For the extended hours DES, the CCGs give all GP practices the option to sign up to the DES each year. The CCGs then record and monitor the practices that have signed up to the scheme via schedules. By way of assurance of compliance with the scheme, the CCGs require practices and the Primary Care Networks (PCNs) to provide a self-declaration of the hours that they have covered for the scheme on a quarterly basis in order to be eligible for payment under the scheme. The Primary Care Team liaise with Finance each quarter to review and validate payments to practices who have met the requirements of the scheme.

14.9 In addition, the CCGs have completed checks of practice websites to ensure that extended hours access is publicised to patients, records of which are kept on the spreadsheets.

14.10 The CCGs also require practices to provide further declarations on core opening hours and extended hours access as part of planning each year for cover for more pressured times of the year such as Easter and Christmas. The declarations also include any subcontracting which may be in place so that the appropriateness of this can be reviewed. The purpose of this is to establish whether the opening or closing times of practices will have an effect on GP availability during these times, and that the requirements of the DES are still complied with around this time of year.

Managing GP List Closures

14.11 It was confirmed for the CCGs that list closure applications are first reviewed by the Primary Care Co-Commissioning Operational Group (PCCOG). The PCCOG will then make a recommendation to the Primary Care Commissioning Committee (PCCC) who will ultimately approve or reject an application for a list to be closed. It was noted that the CCGs refer to and follow the PGM for any list closures when they arise.

14.12 For Medway CCG, the CCG has not developed any checklist, policy or process document based on the guidance around list closure applications. It was advised by the Head of Primary Care for Medway CCG, that there have not been any list closure applications since April 2019. West Kent CCG has developed a checklist / process document based on the guidance and it was advised that there has been three list closure applications since April 2019. It was noted that DGS and Swale CCGs use the same checklist / process document used by West Kent and it was advised that there has been one list closure application in Swale and none in DGS since April 2019.

Recommendation: 1 Ensure that consistent checklists are introduced, for example for planned and unexpected practice closures, in preparation for the merged Kent and Medway CCG, and in line with the Primary Medical Care Policy and Guidance Manual. Priority: 3

14.13 Further testing was completed of the one list closure for Swale which related to The Meads practice. Testing confirmed that the list closure application was considered at the September 2019 PCCOG and PCCC meetings. The outcome of the PCCOG and PCCC meetings was that the application to close the list was approved. As such the practice were notified that it could close its list for a period of 6 months from 1st October 2019, to re-open on 1st April 2020. From the testing of this practice list closure application, it was confirmed that the CCG processes were adequately followed.

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14.14 For the three list closure applications considered for West Kent practices since April 2019, two of these three related to list closures as part of two practices merging. Further testing was completed of the remaining one list closure, which related to Mote Medical Practice and it was confirmed that the list closure application was considered at the PCCOG meeting in July 2019. The outcome of the PCCOG meeting was that the application to close the list was rejected. It was agreed at the meeting that the CCG would work with the practice further to develop plans to help the practice over the next 12 months. From the testing of this practice list closure application, it was confirmed that the CCG processes were adequately followed.

Managing Targeted Patient List Maintenance

14.15 Section 3.4 Part B2 of the PGM, sets out guidance for local patient list checks that could be undertaken by the CCGs. It is noted that such checks are outlined in the guidance as checks that could be undertaken, rather than being mandatory.

14.16 It was advised that the CCGs do not have processes in place in line with the guidance, in order to manage and complete targeted patient list maintenance. However, it was noted that this function is not a delegated function to the CCG (it is a reserved function for NHSE), and as such it is the responsibility of NHSE to put processes in place.

14.17 It was also advised that Primary Care Services England (PCSE) representatives regularly attend the Kent and Medway Primary Care Delegated Co-Commissioning network meetings to provide updates on the work being completed by PCSE. PCSE also circulate regular communications to GP practices and the CCG and evidence was provided to support the communications from PCSE which included updates in May and June 2019 regarding list cleansing and list reconciliation projects. The communications reviewed outlined that nationally, projects were being rolled out to all practices from May 2019. However, it was established that the CCGs have not sought or gained clear assurance from PCSE, of the extent of practices completed by PCSE within the CCGs areas, since May 2019.

Recommendation: 2 The CCGs to obtain assurance and understanding of the outcomes from Primary Care Services England (PCSE), in relation to the work undertaken on targeted patient list maintenance with practices within the CCGs areas.

Priority: 3

14.18 In addition to the above, West Kent CCG track practice list sizes on a quarterly basis, in order to monitor any significant changes in list sizes and investigate with the practices should this be necessary. A practice list size tracker is maintained by the CCG, covering all practices and PCNs, which tracks variance of list sizes over the last 3 years, 12 months, 6 months and quarterly. It was also identified that DGS and Swale CCGs also track list sizes on a monthly basis, however, Medway CCG do not have the same processes in place to track list sizes.

Recommendation: 3 In preparation for the merged Kent and Medway CCG, introduce a consistent practice list size tracker, with regular monitoring and reporting processes.

Priority: 3

Medway - Review of GP Contracts

14.19 Section 2.3 of the PGM outlines the requirement for CCGs to undertake a risk based approach to reviewing contracts with GP practices, together with a rolling programme of deep dive contract reviews. The PGM also outlines the requirement for the CCG to maintain accurate records of all contract reviews to evidence compliance.

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14.20 It was advised by the Head of Primary Care that General Medical Services (GMS) contract documents are reviewed and updated annually, following the issue of the new contracts from NHSE. However, this process is not a risk based review of the contracts in place and adherence to the contract terms and conditions, and does not apply to other contracts, for example Alternative Provider of Medical Services (APMS) contracts.

14.21 It was advised that outcomes from the work and practice visits completed by the Quality and Clinical Variation Teams highlight on a risk basis, practices which may require review across all areas; contractually (performance), quality and safety.

14.22 The CCGs Quality Team practice visits are prioritised and scheduled based on concerns and risks, and that quality practice visits are routinely every 3 years, unless concerns are raised / circumstances / risk dictate the visits to be earlier and / or more frequent. It was advised that the Quality Team use a quality practice visit year planner covering all Medway GP practices.

14.23 It was, therefore, confirmed that the CCG does have a risk based approach to reviewing contracts with GP practices which is driven by performance, quality and safety, as required by the PGM. However, there is not a rolling programme of deep dive contract reviews in place as required by the PGM.

Recommendation: 4 Introduce a rolling programme of deep dive contract reviews as required by the Primary Medical Care Policy and Guidance Manual.

Priority: 3

14.24 Testing identified that the CCG has completed contract reviews and quality visits with the APMS contract provider, DMC who is the provider for St Mary's Island surgery, and five other practices (SMI, Pentagon, Sunlight, Balmoral, and Twydall).

14.25 In addition to these contract reviews, reviews have also been completed for Malling Health practice (connected to a practice closure) and City Way practice (connected to a merger application). Further details of the testing completed regarding Malling Health and City Way practices, is covered below within the practice closure and practice merger sections of this report.

Contract Review - DMC St Mary's Island Practice

14.26 DMC was awarded an interim contract to provide primary care services for the practice from February 2018. Quality visits and contract reviews have been completed, for example in February 2019, records of which have been retained by the CCG. As such in relation to the contract and quality reviews completed for this practice the CCG has complied with the PGM requirement to maintain records of all contract reviews completed.

Contract Review - DMC Five Practice Sites

14.27 Testing identified that DMC took over the provision of primary medical services from five practices in April 2019. As such a six month contract review was required to be completed in October 2019, which was completed in a timely manner.

14.28 It was confirmed that in advance of the review, the CCG had collated intelligence around issues with DMC practices, into a highlight incidents report to inform discussions with DMC in October 2019. Example issues identified were:

• Missing 2 week waits (2WW) e-referral requirements.

• Leadership issues.

• Not being able to get through by phone.

• Responding to a complaint in a timely mannerPage 43 of 202

14.29 Testing of the contract review documents retained by the CCG confirmed that all of the example issues listed above, were raised and discussed with the provider during the contract review meeting.

14.30 It was noted that DMC provided performance reports for review at the contract meeting including;

• Workforce levels, friends and family test results.

• Performance against national requirements (e.g. urgent cancer referral targets, workforce plan), local requirements (complaints procedure, onlineappointments availability, SI reporting, Infection Prevention and Controls), and operational standards (for example; safeguarding requirements,posts and training).

• Did Not Attend (DNA) rates.

• QOF evidence.

• Complaints and significant events reports.

14.31 Testing confirmed that the CCG maintained records of this contract review including; the agenda, meeting notes, and a summary action log which was shared with DMC following the review. The CCG also retained evidence of where certain issues were escalated for action following the review. As such for this contract review the CCG was compliant with the PGM requirement to maintain records of contract reviews completed.

West Kent, DGS and Swale - Review of GP Contracts

14.32 It was advised by the Senior Primary Care Development Manager for West Kent, that GMS contract documents are reviewed and updated annually, following the issue of the new contracts from NHSE. However, this process is not a risk based review of the contracts in place, and adherence to the contract terms and conditions.

14.33 It was identified that the latest contract review processes and reporting to the West Kent PCCC took place in October 2019 where a monitoring, reporting and assurance report around GMS contracts was reviewed. The report included the following updates to the PCCC:

• That the Kent and Medway CCGs are developing a new Primary Care dashboard.

• That West Kent CCG monitors and validates practice performance via practice visits.

• That the current West Kent practice database / tracker is used to track changing levels of practice vulnerability using a set of key indicators whichinclude:

• Key staff changes.

• Merger / branch closure pending.

• List size issues or boundary change requests.

• Number of new initiatives / projects engaged with.

• Section 96 applications, evidence of financial pressure.

• Premises issues.

• Medicines team engagement / intervention feedback.

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14.34 The conclusion of the report was that the CCG was broadly assured that most of the practices were performing and meeting the requirements of their GP contract, with a few practices as exceptions. Two key areas of focus from the review were reported in October, for the Primary Care team to work on:

a) Uptake of access online to GP appointments, prescriptions and test results; and

b) In hours closures

14.35 It was reported that the next GP contract assurance report to PCCC would be in April 2020.

14.36 Testing identified that DGS and Swale CCGs, use a risk profile tool for all practices which RAG rates contract delivery, quality and safety, medicines optimisation, IT, Finance and Premises. The risk profile tool enables identification of practice vulnerabilities to inform prioritisation of work with practices for the CCGs teams.

14.37 It was advised that outcomes from the work and practice visits completed by the CCGs teams highlight on a risk basis, practices which may require closer or more frequent review.

14.38 It was advised that the Primary Care and Quality Team practice visits for West Kent CCG were prioritised and scheduled based on concerns and risks, with no set / default frequency of how often practice visits were to be completed. DGS and Swale CCGs plan annual visits to all practices. However, concerns raised / circumstances / risk, dictate if the visits should be brought forward and / or more frequent. It was confirmed that the Primary Care Team and Quality Team use a practice visit year planner covering all GP practices. It was advised that as at December 2019, the DGS and Swale CCGs Primary Care Teams have carried out annual visits to 22 DGS practices and 13 Swale practices.

14.39 As such it was identified that similar to Medway CCG; West Kent, DGS and Swale CCGs have a risk based approach to reviewing contracts with GP practices which is driven by performance, quality and safety, as required by the PGM. However, there is not a rolling programme of deep dive contract reviews in place as required by the PGM. (See Recommendation 4 above).

West Kent

14.40 Testing identified that the CCG has completed five contract reviews during 2019. Two of the five contract reviews were selected for testing to establish whether the CCG had maintained records of the contract reviews completed. Testing confirmed that records were maintained of the contract reviews completed for the two practices concerned (Grove Park and Waterfield House), in January and August 2019. In addition West Kent has been working with Medway regarding concerns raised around the APMS provider, DMC (referred to above for Medway CCG). Testing with West Kent confirmed that they maintained records of the contract review work being undertaken alongside Medway around DMC, as the provider to one of the West Kent CCG practices. As such for the contract reviews tested, the CCG was compliant with the PGM requirement to maintain records of contract reviews completed.

DGS and Swale

14.41 Evidence was provided regarding six contract reviews that had been completed during 2019. Two of the six contract reviews were selected for testing to establish whether the CCG had maintained records of the contract reviews completed. Testing confirmed that records were maintained of the contract reviews completed for the two practices concerned (Teynham and Hextable surgery), in September 2019. As such for the contract reviews tested, the CCG was compliant with the PGM requirement to maintain records of contract reviews completed.

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Medway - Assurance Processes for Quality, Safety and Performance of GP Practices

14.42 As already reported above (under review of GP Contracts), outcomes from the work and practice visits completed by the CCGs Quality and Clinical Variation Teams highlight on a risk basis, practices which may require prioritised review by the CCG. The Quality Team use a quality practice visit year planner covering all Medway GP practices. Testing further identified that the CCGs Clinical Variation Team (with the quality team), use a dashboard of variation indicators as a tool to inform discussions with practices during the practice visit.

14.43 The clinical variation dashboard used by the CCG includes the following categories of data and indicators:

• CQC inspection outcomes.

• Health Checks completed for patients with learning disabilities.

• Flu jab and other vaccinations uptake rates.

• The practice population.

• GP referrals per specialty.

• A&E non elective admissions.

• Quality Outcomes Framework (QOF) exception results.

14.44 Where any of the above are an outlier as against either a CCG average (compared to other practices), or as against a national target, the indicator is flagged red on the dashboard. The numbers of red flags for the practices inform the prioritisation of which practices pose the most risk for the CCG.

14.45 It was, however, identified that the dashboard does not include other quality indicators and intelligence gathered on a practice such as; friends and family test, patient survey feedback results, and soft intelligence gathered, for example; complaints to the CCG about a practice and CQC intelligence.

14.46 It can be confirmed that there were adequate processes in place at the CCG to gain assurance of the general quality, safety and performance of GP practices. However, the tools and processes used could be further enhanced by inclusion of other soft intelligence gathered. It would be beneficial to have all information and data gathered around a practice's performance, quality and safety, in one place / a central depository for each practice, for all relevant CCG teams / staff to refer to when working with practices during visits.

Recommendation: 5 The practice dashboard and quality assurance tools used by the CCGs to include friends and family test and patient survey feedback results, together with other soft intelligence gathered about a practice, with a central system or depository to be developed in preparation for the one Kent and Medway CCG, to collate the information for each GP practice.

Priority: 3

DGS and Swale - Assurance Processes for Quality, Safety and Performance of GP Practices

14.47 As already reported above (under review of GP contracts), outcomes from the work and practice visits completed by the CCGs Quality Team highlight on a risk basis, practices which may require prioritised review by the CCG.

14.48 Testing further identified that the CCGs Primary Care and Quality Teams use practice dashboards as a tool to inform discussions with practices during the practice visit.

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14.49 The dashboard used by the CCGs includes the following categories of data and indicators:

• Patient demographics.


• GP Patient Survey.

• Quality and Outcomes Framework (QOF) disease prevalence.

• Prescribing.

• Utilisation of Elective and Urgent Care.

14.50 Where any of the above are an outlier as against either a CCG average (compared to other practices), or as against a national target, the indicator is flagged red on the dashboard. The numbers of red flags for the practices inform the prioritisation of which practices pose the most risk for the CCGs.

14.51 It was, however, identified that the dashboard does not include other quality indicators and other soft intelligence gathered on a practice such as; friends and family test, complaints to the CCG about a practice and CQC intelligence.

14.52 It can be confirmed that there were adequate processes in place at the CCGs to gain assurance of the general quality, safety and performance of GP practices. However, the dashboards and tools used could be further enhanced by inclusion of other soft intelligence gathered. It would be beneficial to have all information and data gathered around a practice's performance, quality and safety, in one place / a central depository for each practice, for all relevant CCG teams / staff to refer to when working with practices during visits. (See Recommendation 5 above).

West Kent - Assurance Processes for Quality, Safety and Performance of GP Practices

14.53 As already reported above (under review of GP Contracts), outcomes from the work and practice visits completed by the CCGs Quality Team highlight on a risk basis, practices which may require prioritised review by the CCG.

14.54 Testing further identified that the CCGs Quality Team use Optum practice dashboards as a tool to inform discussions with practices during the practice visit.

14.55 The dashboard used by the CCG includes the following categories of data and indicators:

• Patient demographics.


• GP Patient Survey.

• QOF disease prevalence.

• Prescribing.

• Utilisation of Elective and Urgent Care.

14.56 Where any of the above are an outlier as against either a CCG average (compared to other practices), or as against a national target, the indicator is flagged red on the dashboard. The numbers of red flags for the practices inform the prioritisation of which practices pose the most risk for the CCG.

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14.57 It was, however, identified that the dashboard does not include other quality indicators and intelligence gathered on a practice such as; friends and family test (which is recorded and tracked on a separate schedule), and soft intelligence gathered, for example; complaints to the CCG about a practice, or CQC intelligence.

14.58 It can be confirmed that there were adequate processes in place at the CCG to gain assurance of the general quality, safety and performance of GP practices. However, the tools and processes used could be further enhanced by inclusion of other soft intelligence gathered. It would be beneficial to have all information and data gathered around a practice's performance, quality and safety, in one place / a central depository for each practice, for all relevant CCG teams / staff to refer to when working with practices during visits. (See Recommendation 5 above).

Management of Poorly Performing GP Practices

14.59 The processes in place at the CCGs for identifying poorly performing practices, are mainly driven reactively in response to CQC findings and ratings following inspections. However, as already noted above, there are other processes around quality, safety and performance which are being used more proactively and are being developed further.

14.60 It was confirmed that where decisions need to be taken regarding the management of an identified poorly performing GP practice, including contract management decisions, such decisions would be reviewed initially by the CCGs PCCOG, which would then be escalated where required to the PCCC for decisions to be approved. For example, if a decision was required to issue contract notices to a practice. Further reporting will also be undertaken where appropriate to the Governing Bodies (GB) by way of headline reports from the Primary Care Team. Decisions will also be required from the GB where the implications of the decision exceeds the delegated budgets of the Primary Care Team.

14.61 It was noted that across Medway CCG since April 2019, only one contract notice has had to be issued to a practice. The issue of the contract notice was appropriately considered and approved at the PCCC in June 2019.

14.62 It was noted that across West Kent CCG since April 2019, no contract notices have been issued to any practice.

14.63 It was noted that across DGS and Swale CCGs since April 2019, only two contract remedial notices had been issued to two DGS practices.

14.64 Where appropriate and necessary, the CCGs liaise with CQC throughout the decision making processes, to help inform decision making and action to be taken with the practices concerned.

14.65 The Head of Quality and Safety for Primary Care and the Head of Primary Care (Medway CCG), the Senior Primary Care Development Manager and the Head of Quality (West Kent CCG), and the Head of Primary Care (DGS and Swale CCGs), maintain regular and frequent contact with CQC representatives for the region, such that soft intelligence (ad hoc information around a practice), will be exchanged between the CCGs and CQC, to inform any action which then may become necessary to take. However, it was noted that the ongoing liaison between the CCG and CQC is not formalised as minuted meetings but more informal telephone meetings and some face to face meetings. (See Recommendation 5 above)

14.66 Testing did identify that West Kent CCG records CQC intelligence gathered and records CQC inspections completed or likely to be scheduled, on a spreadsheet CQC report, which is referred to by the Primary Care and Quality Teams.

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Medway

14.67 Testing identified three example practices where concerns had been raised during 2019 about the quality of services by the practices, to which the CCG was required to respond and act upon those concerns. These examples were DMC practices (as already covered above regarding contract reviews); and the practices discussed below, including the closure of a practice (termination of an APMS contract), and the merger of two practices. Further details of testing completed regarding these practices is covered below.

DGS and Swale

14.68 In addition to the practices reviewed above under contract reviews, testing identified that the CCGs had identified two further practices within each CCG, where concerns had been raised about the quality of services by the practices, to which the CCGs were required to respond and act upon those concerns. The two Swale CCG practices were London Road and Lakeside. The two DGS practices were Old Road West Surgery and Elmdene. Testing confirmed that for all four practices the CCGs became aware of concerns and acted upon these in a timely manner, completing practice visits to understand the challenges the practices were experiencing, and to offer support to the practices where appropriate. The outcome of the practice visits were that actions for improvements were agreed with the practices, which were reported and monitored appropriately by the CCGs.

West Kent

14.69 In addition to the practices reviewed above under contract reviews, testing identified that the CCG had identified two further practices, where concerns had been raised about the quality of services by the practices, to which the CCG was required to respond and act upon those concerns. The two practices were Abbey Court and Wallis Avenue. Testing confirmed that for both practices the CCG became aware of concerns and acted upon these in a timely manner, completing practice visits in May and August 2019 to understand the challenges the practices were experiencing and to offer support to the practices where appropriate. The outcome of the practice visits were that actions for improvements were agreed with the practices, which were reported and monitored appropriately by the CCG.

Managing Practice Mergers

14.70 Any applications for practice mergers received will in the first instance be reviewed by the CCGs PCCOG. The PCCOG will then make recommendations to the PCCC who will ultimately approve or reject an application. It can be confirmed that the CCGs refer to and follow the PGM guidance for practice mergers when they arise. Practices wishing to merge are required to complete an application to the CCGs, which sets out as part of the application a plan for the merger including for example, engagement plans with patients. It can be confirmed that this approach and process aligns to the PGM guidance. In addition it was noted that West Kent, DGS and Swale CCGs have in place a merger process flow chart document which aligns to the PGM guidance, however, Medway CCG do not have this in place. (See Recommendation 1 above)

Medway

14.71 It was advised by the Head of Primary Care that since April 2019, there has only been one practice merger application received and processed by the CCG. The merger concerned City Way and Borstall Village practices wishing to merge. Testing identified that quality visits and contract reviews had been completed with the two practices before the merger application was made.

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14.72 The application was received and reviewed by the PCCOG early November 2019 where it was recommended to the PCCC that the merger application be approved. The PCCC considered the application late November 2019. The papers presented at both meetings included all expected areas including; the application, boundary maps, Local Medical Committee consultation comments, comments from neighbouring practices, and patient engagement and communications. The merger application was approved by the PCCC at the November 2019 meeting and the practices are planning to merge on the 31st December 2019.

14.73 From the testing it was confirmed that CCG processes were appropriately followed in the case of this practice merger.

DGS and Swale

14.74 It was advised that there has been three practice mergers across DGS and Swale CCGs. There has also been examples of contract novations for some practices to become limited companies, since April 2019.

14.75 The merger in Swale CCG concerned Lakeside practice merging with Milton Regis practice. The merger in DGS CCG concerned three practices merging (the Forge, Gateway, and Whitehorse) to form one limited company practice known as Springhead Health.

Lakeside and Milton Regis

14.76 The application was made by the practices in May 2019 and was reviewed by the PCCC in August 2019. The PCCC approved the merger application, with the planned merger date being 1st January 2020. The application and review process considered all expected areas including; patient consultation, neighbouring practices consultation, communications and engagement plans, and a mobilisation plan.

The Forge, Gateway, and the Whitehorse to become Springhead Health

14.77 The application was made and considered by the PCCC and GB in June and July 2019 where the merger application was approved. The application and review process considered all expected areas including; patient consultation, neighbouring practices consultation, communications and engagement plans, and a mobilisation plan.

14.78 From the testing it was confirmed that the CCG processes were appropriately followed in the case of these practice mergers.

West Kent

14.79 It was advised that there has only been one practice merger application received and processed by the CCG since April 2019. The merger concerned Northumberland Court and Grove Park practices wishing to merge. The application was for the two practices to merge with the subsequent retirement of the one single handed GP from the contract, and closure of the single handed GPs premises. Testing identified that quality and contract reviews had been completed with the two practices before the merger application was made.

14.80 The application was received and reviewed by the PCCOG in May 2019 where it was recommended to the PCCC that the merger application be approved. The PCCC considered and approved the application in June 2019. The papers presented at both meetings included all expected areas including; the application, boundary maps, Local Medical Committee consultation comments, comments from neighbouring practices, and patient engagement and communications. The merger application was approved by the PCCC with the practices merging in October 2019.

14.81 From the testing it was confirmed that the CCG processes were appropriately followed in the case of this practice merger.

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Managing Practice Closures

14.82 Similar to the process for managing practice mergers outlined above, the start of the process for managing a planned practice closure is the receipt of an application from a practice wishing to close. It can be confirmed that the CCGs consider factors such as the impact of a proposed closure, including; access, quality of care, value for money, other local factors, and consultation with patients and the public. Any application to close a practice will first be considered by the PCOG and then escalated to the PCCC for consideration and a decision to approve or reject the application, based on the PCOG recommendations. It can be confirmed that the CCG refers to and follows the PGM guidance for practice closures when they arise. In addition it was noted that West Kent, DGS and Swale CCGs have in place a practice closure process flow chart document which aligns to the PGM guidance, however, Medway CCG do not have this in place. (See Recommendation 1 above)

14.83 It was noted that the PGM guidance outlines that for a planned closure of a practice the process should commence with the CCG, 9-15 months before the end of the contract with the provider. The guidance outlines that in relation to unplanned practice closures the process at the CCGs should involve rapidly dispersing the patient list, completing patient engagement and communications, with at least two reminders being sent to patients affected by the closure, and for the CCGs to ensure the secure and timely transfer of patient records. However, it was noted that the CCGs do not have defined processes or an assurance checklist in place, for practice closures (planned or unplanned / unexpected). (See Recommendation 1 above)

Medway

14.84 It was advised by the Head of Primary Care that there has only been one practice closure in Medway since April 2019, which related to Malling Health (Parkwood Health Centre and Rainham Healthy Living Centre). The APMS contract provider terminated the contract early, with the notice period ending on 31st August 2019. The termination of the contract and in effect closure of the practice, was managed by the CCG as a 'lift and shift' of patients to a neighbouring GMS contract practice. The neighbouring practice shared the same premises with the outgoing provider.

14.85 Testing identified that as required by the CCG's own processes and the PGM guidance, the termination of the contract was reported and considered by the PCCC in July 2019, where the most viable option to 'lift and shift' all patients to a neighbouring practice was approved to proceed. Testing further identified that further reporting was completed in August and October 2019 to both PCCOG and PCCC around quality issues to be addressed by the practice when taking over the care for the patients transferred from 1st September 2019. It was also agreed in September 2019 that a quality visit would be completed with the new practice in January 2020.

14.86 From the testing it was confirmed that the CCGs processes and the PGM guidance, were adequately followed in this case.

DGS and Swale

14.87 During the course of the review, unexpected GP practice closures occurred within DGS CCG. Two practices (Elmdene and Joydens Wood), with two branch clinics, were closed and unable to provide clinical services following CQC inspections at the end of November 2019. At the time of the audit, it was too early to review if the CCG had managed the unexpected closures in line with the PGM guidance. Until these practice closures, there had been no other practice closures in DGS or Swale CCGs in 2019 / 2020.

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West Kent

14.88 It was advised that there has only been one practice closure in West Kent since April 2019, other than the site closure at Grove Park as part of the merger discussed above. The closure related to Clanricarde Medical Centre Branch (Rowan Tree Surgery). Testing identified that as required by the CCG's own processes and the PGM guidance, the termination of the contract was reported and considered by the PCCC in October 2019, following review and recommendation from PCCOG to approve the application. Testing confirmed that the PCCC approved the application at the meeting in October 2019, with the branch practice scheduled to close in January 2020.

14.89 From the testing it was confirmed that the CCGs processes and the PGM guidance, were adequately followed in this case.

Operational Risk: Failure to identify opportunities to operate more efficiently or to be prepared for forthcoming changes.

Changes and Developments in Processes for the Kent and Medway CCG from April 2020.

14.90 The Deputy Managing Director (DGS and Swale CCGs) and the Head of Primary Care and Medicines Optimisation (WK CCG) advised of the following changes which will impact on existing processes (as already covered above in this report):

• The CCGs primary care staff and teams are already in the process of merging to be one Primary Care Team. The Primary Care Strategy and teamstructure going forward will be based around three directorates -

1. Contracting (immediate term - working with practices now and within the next 12 months, and annually as required).

2. Development and Delivery (medium term - working with practices over the next 3 years to develop and improve the services being providedby practices).

3. Strategy and Estates (longer term work and planning - over the next 3-7 years including planning for growth work).

• The introduction of the Aspyre system which has started to be rolled out in recent months, starting with West Kent CCG. The system will eventuallybe used by all of the MNWK CCGs. The system is a task and project management system to cover all GP practices and the PCNs, across all ofthe CCGs.

• Pilot of the Apex system - a demand and capacity management tool for practices being piloted in the Ridge PCN in West Kent.

• Work is being undertaken across Kent and Medway, together with the East Kent CCGs, to progress a work plan of policies and processes to bealigned in primary care, and to assign areas to work on to team members.

• Planning for growth work; working with PCNs across West Kent, DGS and Swale CCGs. This work has involved reviewing with practices,population growth, and development plans for the future, to plan the development and delivery of the care that will become necessary to meet theincreases in demand for services.

14.91 Discussions with primary care staff across all four of the CCGs identified that difficulties have been experienced when working with Primary Care Support England (PCSE). Difficulties have been experienced with the timeliness and accuracy of letters to be sent out to patients, and the transfer of patient notes, for example when a practice closes and patient lists are dispersed. It was advised by the Deputy Managing Director that such issues have been escalated within PCSE (Capita) and with NHSE.

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Date: March 2020 Reporting Officer: Marcos Menager: Primary Care Head of Quality and Workforce Tracey Creaton: Deputy Chief Nurse

Agenda Item: 8

Lead Director: Paula Wilkins Version: 1.0 Report Summary:

Since the last report in February there have been no changes to report in March. The Quality and Nursing Team continue to work alongside the Primary Care Team, the Federation and the Training Hub to ensure that delegated commissioning responsibilities are discharged. Further analysis of data will anticipate & direct interventions and support of individual practices as well as the formation of PCN. Heads of Primary Care Quality across Kent and Medway are developing a standard approach around future contract reporting based on quality improvement outcomes. CQC have not performed any site visits. Further analysis of the Friend and Family Test will be available at the end of the financial year. Serious Incidents; West Kent has one open investigation linked with other investigations taking place in North Kent (Medway , DGS and Swale) due to the Governance nature of the incident.



Strategic Goal D - Service quality and patient safety

Service providers commissioned, and performance managed, to promote and support the highest standards of care, patient safety

West Kent CCG Nursing and Quality Team Report


Recommendation: For the Primary Care Co-commissioning Committee to Note

For further information or for any enquiries relating to this report please contact: Paula Wilkins, Chief Nurse

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and patient experience.


Strategic Goal D - Failures of clinical governance in the system could lead to: Less safe services; Failure to safeguard vulnerable individuals; or failure to deliver high quality care for patients resulting in poorer health outcomes for local people or actual patient harm.


N/A

Resource implications: N/A Legal implications including equality and diversity assessment

This document has taken into account Equality and Diversity best practice.


Has an equality assessment been undertaken? ☐Yes☒Not applicable


Conflicts of interest are declared and recorded at the Quality Committee


The full quality report includes patient feedback reported by the providers.

Report history: N/A

Appendices N/A

Next steps: N/A

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Patient focused, providing quality, improving outcomes

West Kent CCG Nursing and Quality Team Report for Primary Care

February 2020

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NHS West Kent Clinical Commissioning Group

Introduction The Nursing and Quality team reviews and scrutinises data from a variety of sources and obtains local intelligence through dialogue and meetings with providers, lead commissioners and external stakeholders including the Care Quality Commission and NHSE. This report details the most recent quality issues being monitored and addressed by NHS West Kent CCG, with updates since the last PCCC meeting.

Primary Care Serious Incidents (SIs) There are currently no serious incident (SI) open.

Care Quality Commission (CQC)

CQC Inspections 2019

There have been no further Primary Care CQC inspections across West Kent since the last PCCC report.

CQC Annual Regulatory Reviews (ARRs) as per end of December 2019

West Kent End of Dec CQC position

West Kent General Practice Rate Number Name of practice

Outstanding 1 Drs G Streeter, N. Potter, J Morgan and Estall

Good 49 Requires Improvement

3 Yalding Surgery Old School Surgery Abbey Court Medical

Not formally rated 1 Albion Place Medical Practice Pending Process 1 Warders Medical Total 55

West Kent Federations Rate Number Name of practice Good West Kent Medical Ltd

Independent Health Rate Number Name of practice Good 2 i-GP Virtual Dr

Screen Cancer UK Head Office

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Not formally rated THMG Maidstone Clinic Pending Process Illuminate Skin Clinic

Practices not currently rated

Of the fifty five practices within WKCCG, two practices remain with no CQC rating, either due to a change of provider or changes to registration that resulted in legal entity change. Please see Table 3.

This position has changed from the last Primary Care report where there were five practices without a rating due to registration changes.

Table 3 GP practices currently without a CQC rating (19th September 2019)

Practice Details

Albion Place Medical Practice New Registration accepted by CQC on 13th June 2018. New Registration under DMC Healthcare on 24th May 2019

Warders Medical No data available

GP Practices Friends and Family Test

Making the Friends and Family Test (FFT) available to the GP practice patients, and submitting data to NHS England, is a contractual requirement. The full information can be access on https://www.england.nhs.uk/publication/friends-and-family-test-data-november-2019/ Each practices must submit data to NHS England each month through the Calculating Quality Reporting Service (CQRS).

Table 4 below, shows that GP Practices FFT submissions to date in the past 12months.

As shown, the submission rates for West Kent practices since August 2019 have increased from 30.5% to 33.9%.

WKCCG is continuing promoting individual submission and supporting and/ or guiding practices to address the factors contributing to the low submissions.

• Federation Head of Nursing and Quality is working collaboratively with the WKCCG.

• The CCG Head of Quality and Primary Care Team have incorporated the monitoring andfollow-up of FFT with individual practices as part of the overall engagement and review ofpractices.

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https://www.england.nhs.uk/publication/friends-and-family-test-data-november-2019/


Table 4 GP Practices FFT Submissions to Date

GP Patient Survey July 2019 Highlights

• The GP Patient Survey (GPPS) is an England-wide survey, providing practice-level data about patients’ experiences of their GP practices.

The full report can be access here: https://www.gp-patient.co.uk/Slidepacks2019#W under NHS West Kent CCG.

The below slides aim to highlight the key areas of the above mentioned survey:

FFT % Recommend Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19Survey

ResponsesAMHERST MEDICAL PRACTICE no dataKINGSWOOD SURGERY * 71.4% 100.0% 100.0% 100.0% NA 90.0% * 100.0% 83.3% 100.0% 100.0% 100.0% * NA 100.0% * 3ALBION PLACE MEDICAL PRACTICE 69.2% 68.8% 68.9% 69.8% 80.0% 81.6% 38EDENBRIDGE MED PRACTICE 95.5% 66SPELDHURST & GREGGSWOOD MEDICAL GROUP no dataGREENSANDS 77.1% 85.0% 233CLANRICARDE MEDICAL CENTRE 61.5% 56.3% 67.6% 78.4% 68.0% 71.4% 65.2% 68.6% 58.8% 65.9% 77.3% 66.0% 81.3% 73.7% 65.7% 65.2% 87.5% 32BOWER MOUNT MEDICAL PRACTICE no dataHILDENBOROUGH MEDICAL GROUP * 100.0% 80.0% 100.0% 100.0% * 100.0% * * * * 83.3% 83.3% 100.0% * 83.3% 100.0% 6GROSVENOR & ST JAMES MEDICAL CENTRE no dataTONBRIDGE MEDICAL GROUP 90.0% 86.2% 86.0% 88.0% 85.7% 91.8% 86.0% 90.2% 98.0% 88.0% 50NORTH RIDGE MEDICAL PRACTICE 100.0% 96.9% 96.3% 100.0% 100.0% 97.1% 90.0% 100.0% 100.0% 98.6% 97.1% 98.6% 98.3% 97.8% 91AYLESFORD MEDICAL CENTRE 81.3% 235WARDERS MEDICAL CENTRE 100.0% no dataDR SINHA GC 88.9% 70.8% 66.7% 75.0% 72.7% 100.0% 77.8% 83.3% 100.0% 100.0% 100.0% * 90.0% 92.6% 95.7% no dataBEARSTED 94.3% 95.2% 96.8% 91.5% 98.0% 95.6% 96.5% 96.0% 95.5% 97.0% 97.2% 97.8% 94.6% 93.4% 96.0% 95.8% 192MOTE * * * NA NA * * * * * * * * * * 3THORNHILLS MEDICAL PRACTICE 83.8% * no dataSNODLAND MEDICAL PRACTICE 81.3% 80.4% 80.0% 85.1% 87.3% 85.5% 78.9% 68.6% 58.8% 78.9% 76.0% 77.2% 75.5% 82.9% 146BREWER STREET 85.7% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% * 83.3% NA 100.0% 100.0% 90.0% 90.0% 84.6% 13WESTERHAM PRACTICE NA * * NA * * NA * no dataLEN VALLEY PRACTICE no dataBLACKTHORN no dataTHE COLLEGE PRACTICE no dataABBEY COURT 84.2% no dataALLINGTON CLINIC no dataTOWN MEDICAL CENTRE 86.2% 84.8% 86.4% 85.2% 83.7% 215HEADCORN SURGERY 89.5% 86.8% 85.3% 85.3% 93.0% 80.4% 83.5% 88.4% 83.1% 93.1% 78.0% no dataWOODLANDS HEALTH CENTRE NA * * * * 2BOROUGH GREEN MEDICAL PRACTICE * * * * * * * * * NA * no dataOTFORD MEDICAL PRACTICE * * * 83.3% 84.0% 64.3% no dataWEST MALLING GROUP PRACTICE * no dataST ANDREWS MEDICAL CENTRE 100.0% no dataYALDING 100.0% 96.0% 97.3% 99.0% 97.1% 97.7% 172RUSTHALL MEDICAL PRACTICE 97.1% 98.1% 97.0% 98.6% 95.8% 96.4% 96.5% 97.6% 97.1% 98.6% 94.9% 100.0% NA * * NA no dataWATERFIELD HOUSE SURGERY * NA NA NA * NA * * NA NA NA NA * * * 4HOWELL SURGERY * NA NA * NA NA NA * 44.4% * 11.8% 17THE VINE MEDICAL CENTRE 70.0% * * 100.0% 81.8% 61.5% 88.9% 80.0% 42.9% * * no dataLAMBERHURST 91.8% 97.8% 95.9% 95.9% 49WATERINGBURY 100.0% 96.3% 100.0% 100.0% 98.0% 98.0% 87.0% 88.0% 100.0% 95.7% no dataST JOHN'S MEDICAL PRACTICE 100.0% 7MARDEN MEDICAL CENTRE * 100.0% * 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% no dataOLD PARSONAGE SURGERY 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 98.0% 92.0% 98.0% 85.7% 88.6% 44SUTTON VALENCE GROUP PRACTICE 98.8% 98.8% 96.1% 98.1% 98.0% 98.0% 98.0% 96.0% 94.1% 92.0% 95.8% 89.8% no dataPHOENIX MEDICAL PRACTICE no dataOLD SCHOOL SURGERY 89.6% 93.8% 93.5% 78.4% 91.3% 46NORTHUMBERLAND COURT 95.7% 92.2% 90.4% 90.4% 82.6% 82.1% 94.2% 95.5% 87.8% 91.3% 100.0% 100.0% 97.3% 98.8% no dataTHE CRANE 100.0% 97.4% 96.3% 100.0% 100.0% 100.0% 94.4% 100.0% 100.0% 100.0% 83.3% 73.3% 59.6% 72.4% 86.1% 36WALLIS AVENUE 78.6% 100.0% NA NA NA 72.2% * NA 66.7% 77.8% no dataMALLING HEALTH FOUR no dataLANGLEY no dataWISH VALLEY SURGERY no dataORCHARD END no dataTHE ORCHARD MEDICAL CENTRE 83.3% NA NA * NA 83.3% 6HADLOW MEDICAL CENTRE * * no dataLONSDALE MEDICAL CENTRE * NA NA NA NA NA NA NA NA 100.0% *COBTREE 98.4% 100.0% 100.0% 100.0% 95.0% 90.9%ALLINGTON PARKSOUTH PARK MEDICAL PRACTICE

1,706CCG % of practices submitting returns 25.4% 27.1% 27.1% 25.4% 28.8% 23.7% 28.8% 25.4% 30.5% 25.4% 22.0% 25.4% 30.5% 30.5% 27.1% 30.5% 33.9%

England Recommend 90% 90% 90% 90% 90% 90% 90% 90% 89% 89% 89% 89% 90% 90% 90% 91% 93%

CCG Recommend 88.6% 89.8% 90.2% 90.1% 90.0% 90.0% 90.0% 89.8% 89.4% 89.4% 89.4% 89.5% 90.0% 89.9% 90.3% 90.5% 93.2%

1

Friends and Family (FFT) Data Updated 28/12/2019No data or Zero

Response for 3 Months

013

2

02302033111

0

00330000003

0

00001300102

0

12300323000

Total CCG Response0

010000

Total CCG Response

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https://www.gp-patient.co.uk/Slidepacks2019#W


Page 59 of 202


Page 60 of 202

Date: 24/03/2020 Reporting Officer: Martin Kayes Agenda Item: 9 Lead Director: Reg Middleton Version: 1.0 Report Summary: A summary of the financial performance of PCCC budget at Month 11 (February 2020) is detailed below along with other key primary care budgets. A summary of the forward investment plan, which gives an overview of the planned level of expenditure between 2019/20 and 2023/24 set against expected allocation.



E – Sustainable Finances


Paper supports the mitigation of risk relating to: Loss of control over provider activity and system finances, resulting in CCG being unable to invest in service development and ultimately breaching statutory duties


N/A

Resource implications: N/A Legal implications including equality and diversity assessment

N/A

Primary Care Commissioning Committee (PCCC) Finance Report

This paper is for: For Information

Recommendation: For review – committee required to note the financial position of the PCCC budget as reported to the governing body for Month 11 for 2019/20 and the forward investment plan.

For further information or for any enquiries relating to this report please contact: Martin Kayes, Senior Finance Manager – West Kent CCG ([email protected] )

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Has an equality assessment been undertaken? ☒Not applicable


N/A


N/A

Report history: N/A

Appendices N/A

Next steps: N/A

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Primary Care Co-commissioning Finance Update

1.0 2019/20 Finance Update

1.1 Summary of Delegated Co-commissioning

Primary Care Co-commissioning is forecast to be £1.170m below planned expenditure at 2019/20 year-end. The performance of the budget will continue to be reviewed regularly to incorporate any financial risks or mitigations which may arise during the new financial year.

1.2 A summary of the financial performance of PCCC budget at Month 11 (February 2020) is detailed below along with other key primary care budgets. The forecast PCCC expenditure for the 2019/20 financial year is £62.922m. This sum is based on an accruals system of accounting.

1.3 GP Contracts

The year to date financial position is 0.7% below plan due principally to a downward revision in the weighted population in October 2019. GP contract expenditure is forecast to be £271,000 below the £42.174m plan by year-end.

1.4 Primary Care Networks & Enhanced Services

The PCN forecast outturn is a £398,000 under-spend, which principally comprises of an anticipated £70,000 overspend on extended hours access and a £469,000 under-spend on additional role reimbursement.

PCCC Category of Expenditure Annual Budget (£000's)

YTD Budget M11 (£000's)

YTD Actual M11 (£000's)

YTD Variance M11 (£000's)

Forecast Outturn M11 (£000's)

Forecast Variance M11 (£000's)



Delegated Co-commissioningGP Contracts (GMS, PMS, APMS) 42,174 38,660 38,402 -258 41,903 -271 41,933 41,933Primary Care Networks 2,462 2,257 1,833 -423 2,064 -398 2,064 2,152Enhanced Services 877 804 841 37 890 13 917 917Quality and Outcomes Framework 5,973 5,475 5,083 -393 5,513 -460 5,513 5,613Premises 6,447 5,910 6,285 375 6,625 178 6,598 6,498Other GP Payments 5,366 4,919 4,522 -397 5,135 -231 5,323 5,496Operating Budget 63,300 58,025 56,966 -1,058 62,130 -1,170 62,348 62,6090.5% contribution to contingency 313 287 287 -0 313 0 313 313Total PCC Allocation 63,613 58,312 57,253 -1,058 62,443 -1,170 62,661 62,922

Key Primary Care BudgetsAPCS 3,324 3,047 2,365 -682 2,733 -591 2,733 2,777GP IT 2,091 1,917 1,592 -325 1,735 -356 1,860 1,860GPFV 4,915 4,505 4,492 -13 4,915 0 5,495 6,582PCN Support 744 682 682 0 745 1 745 745Transformation Fund (£3 per Head) 258 237 248 12 258 0 258 258Transformation (Other) 665 610 589 -21 670 5 665 665Total Other Primary Care 11,997 10,997 9,968 -1,029 11,056 -941 11,756 12,887

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The majority of the additional role under-spend is due to the revision of financial entitlements by NHSE after initial budget setting. However, it is anticipated that there will be £85,000 slippage in reimbursement for clinical pharmacists.

The 2019/20 forecast outturn for enhanced services is £890,000, a 1.5% over-spend driven by marginally higher than anticipated minor surgery DES activity.

1.6 Quality Outcomes Framework (QOF)

The QOF outturn for 2019/20 is forecast to be £5.513m (£460,000 below plan). This is due to a £200,000 benefit from the over-provision of QOF achievement in 2018/19 and a corresponding reduction in anticipated achievement for 2019/20.

1.7 Premises

It is anticipated that premises expenditure will be £178,000 above planned expenditure by year-end. There is currently £194,000 of outstanding rate rebate to be recovered, of which £175,000 was accounted for in the 2018/19 CCG accounts.

1.8 Other Delegated GP Payments

The forecast outturn for other delegated GP payments is an under-spend of £231,000. This consists of £84,000 of GP Improved Access expenditure not funded through CCG allocation but is offset forecast under-spends in two areas;

• Seniority payments, which are £90,000 lower than originally anticipated.• Premises development fees of £210,000 originally anticipated to be in

2019/20 which will not be incurred until later in 2020.

PCCC Analysis of PCN and Enhanced Service Expenditure

Annual Budget (£000's)








DESDES Minor Surgery 762 699 725 27 770 8 770 797DES Violent Patients 16 14 20 5 21 5 21 21DES Learning Disability Health Check 95 87 92 5 95 0 95 95DES OOAR In Hours Urgent Care 4 4 4 0 4 0 4 4

877 804 841 37 890 13 890 917

PCN DESPCN DES Clinical Pharmacist 470 431 128 -302 169 -300 169 254PCN DES Social Prescribing Link 400 366 208 -158 231 -169 231 231PCN DES Participation 844 774 755 -19 839 -5 839 844PCN DES Extended Hours Access 498 457 513 56 569 71 569 572PCN DES Clinical Director 250 229 229 0 255 5 255 250

2,462 2,257 1,833 -423 2,064 -398 2,064 2,152Total PCC Allocation 3,339 3,061 2,674 -386 2,953 -386 2,953 3,068

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1.9 Alternative Primary Care Services (APCS)

APCS is £682,000 below plan for the year to February and forecast to end the year £591,000 below plan.

It is anticipated that the current level of under-spending will not continue as the blood pressure monitoring, echo cardiogram (ECG) and phlebotomy elements of the Primary Care Quality Standard (PCQS) commenced in October. Activity levels in these areas will be closely monitored.

1.9 GP Forward View

Forecast outturn for GP Forward View is anticipated to be at a break even position in 2019/20.

• GP Improved Access (£2.839m). £2.755m is funded by allocation, the balanceof the budget is retained from 2018/19.

Financial values in the summary table include K&M STP GPFV allocations which are being hosted by the CCG;

• PCN Support Funding (£1.392m)

• GP Retention (£404,000)

• GP Practice Resilience (£254,000)

• GP Development, Reception and Clerical Training (£318,000)

• GP Online Consultation Software Systems (£487,000)

• GP Workforce Training Hubs (£319,000)

• GP Fellowships Core Offer (£287,000)

• GP Fellowships Aspiring Leaders (£366,000)

PCCC Analysis of PCN and Enhanced Service Expenditure

Annual Budget (£000's)








APCS / PCQSLES Anticoag & DVT 1,068 979 877 -102 939 -129 939 989LES Blood Pressure Monitoring 163 150 40 -110 81 -82 81 81LES Care Homes 623 571 511 -60 562 -61 562 562LES ECG 391 359 6 -353 106 -285 106 106LES High Risk Drug Monitoring 304 279 272 -7 304 -0 304 304LES Minor Injuries 129 118 97 -21 109 -20 129 129LES Palliative Care 81 74 74 0 81 0 81 81LES Phlebotomy 450 412 390 -22 435 -15 391 391LES Women's Health 94 86 88 2 94 0 94 94LES Other 22 20 10 -10 22 0 46 40Total 3,324 3,047 2,365 -682 2,733 -591 2,733 2,777

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To date, the practice resilience and reception and clerical training funds have been merged and deployed to Kent and Medway CCGs. This included an award to West Kent CCG of £128,000 for six PCN / practice support bids and a £10,000 share of a joint care navigation bid with Swale and DG&S CCGs.

A further £106,000 has been allocated from the GP retention allocation to the West Kent Education Network, which has received a further £83,000 of Workforce Training Hub money following STP agreement in January.

1.10 Expenditure Analysis by PCN

Monitoring of delegated expenditure by populations continues and has been adapted to now be based on Primary Care Networks. This will be reported by exception or where any change takes place.

2.0 Primary Care Forward Investment Plan

2.1 Introduction

The Forward Investment Plan sets out projected expenditure over the next five years and compares with anticipated funding allocations over the same period to determine whether there may be future financial pressures.

The CCG allocation for 2019/20 is £63.613m and includes a non-recurrent element of £941,000 in relation to dispensing doctors’ fees.

2.2 Summary

The principal revisions of the forward investment plan between December (Month 09) and February (Month 11) are in two areas;

• GMS contract payment uplift is 3.98% and not the originally published 2.3%.This change increases the level of anticipated GMS contract expenditure by inexcess of £600,000 per annum from 2020/21.

• The Additional Roles Reimbursement Scheme (ARRS) has been extendedbeyond that originally stated in the NHSE guidance and includes 100%reimbursement for a greater number of roles than originally planned,compared to the previously stated 70%.

The table below is from the NHSE update to the GP contract agreement, which identifies the level of further investment in ARRS nationally.

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The consequences of this amendment to West Kent CCG anticipated expenditure is set out in the table and graph below. The expected additional cost in 2020/21 is £1.385m and rises to £4.171m by 2023/24.

It is assumed that NHSE will fully fund the additional costs incurred from the guidance update but this has not yet been confirmed.

In addition to the current medium to long-term financial forecast, the Forward Investment Plan also includes adjustments with regards to assumptions made about future allocations.

The assumptions about the other PCN payments described in the previous iteration of the forward investment plan remain unchanged. In summary they are;

• Practice Network Participation Payment - £1.76 per weighted patient is fundedthrough the primary care allocation. Uplifts between 2019/20 and 2023/24include 1.25% annual demographic growth and inflation at 1%.

PCN Funding Stream 2018/19 2019/20 2020/21 2021/22 2022/23 2023/24PCN Participation £844,679 £863,790 £883,333 £903,319 £923,756PCN Additional Roles £485,510 £3,442,471 £5,972,287 £8,221,901 £11,304,113PCN Extended Hours Access DES £593,865 £572,000 £723,905 £745,785 £768,326 £791,549PCN Clinical Lead £246,545 £330,245 £337,717 £345,358 £353,171Grand Total £593,865 £2,148,734 £5,360,411 £7,939,122 £10,238,904 £13,372,590

£0

£2,000,000

£4,000,000

£6,000,000

£8,000,000

£10,000,000

£12,000,000

£14,000,000

2018/19 2019/20 2020/21 2021/22 2022/23 2023/24

Changes to PCN Funding

PCN Clinical Lead

PCN Extended HoursAccess DES

PCN Additional Roles

PCN Participation

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• Clinical Director - £0.51 per registered patient is funded through the primary careallocation and is payable from July 2019 to March 2020 (£0.057 per patient permonth). The full year effect of this (£0.68 p.a.) will apply in 2020/21. Subsequentuplifts until 2023/24 include 1.25% annual demographic growth and 1% inflation.

• Primary Care Network Support – £1.50 per registered patient per annum, whichis funded through the core CCG allocation.

2.3 Forward Investment Financial Planning Assumptions

• GP co-commissioning allocation for 2019/20 is £63.613m, including a dispensingdoctors' allocation of £941,000 in June. The WKCCG Allocation rises to £77.014min 2023/24, including £727,000 for dispensing doctors.

• Demographic growth is estimated to be 1.25% between 2019/20 and 2023/24.This is based on historical levels of growth and the General Practice EstatesStrategy, which includes data on the level of future housing development. It isapplicable to contract payments, enhanced services and dispensing costs.

• Global sum uplift assumed to be 3.98% in 2020/21, 2.8% in 2021/2022, 2.5% in2022/23 and 2.7% in 2023/24 as set out by NHSE in the Investment and evolutiondocument and the subsequent GMS contract changes 2019/20 letter.

• QOF point price uplift is 4.73% in 2019/20 and assumed to follow the global sumannual uplifts until 2023/24.

• QOF achievement budget planning is based on a phased increase up to 100%achievement from 2023/24.

• It is assumed that there will be a price uplift of 1% p.a. to the current set ofenhanced schemes until 2023/24.

• The financial impact of the GP Estates Strategy is included in the ForwardInvestment plan and includes estimates for rent, rates and one-off costs, such aslegal fees and stamp duty land tax.

• The outstanding rent reviews are included in the premises uplift in 2019/20. Therent growth adjusts for the time elapsed since the last review and the mean rentincrease of West Kent GP practices over the past five years.

• The non-recurrent impact of rate rebates is adjusted for in 2019/20.

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• Inflation assumed to be 1% from 2019/20 but is only applicable to those itemswhich do not include a specific uplift methodology.

• The forward plan for additional roles expenditure is based on the indicativemaximum reimbursable values presented in the ‘Additional RolesReimbursement Scheme Guidance’.

• Recurrent £250,000 GP practice resilience fund until 2023/24.

• A provision for the Primary Care Quality Standard (PCQS) based on theanticipated costs of Treatment Room, Wound Care and Community ECG servicesfrom October 2019.

• GP improved Access is currently funded through CCG allocation. This isanticipated to continue until 2021/22, when the scheme will become part of thePCN DES. As allocation has not yet transferred to delegated co-commissioning,costs have also not been included. It is anticipated that the net effect of fundingand expenditure will be cost neutral.

2.4 Forward Investment Financial Plan

Summary PlannerCategory Outturn 2018/19 FOT 2019/20 (per

M11)Plan 2020/21 Plan 2021/22 Plan 2022/23 Plan 2023/24

GP Co-commissioning Allocation £60,808,999 £63,613,000 £66,701,000 £69,873,000 £73,246,000 £77,014,000

FOT / Planned Expenditure incl. 1/2 Contingency £59,145,680 £61,786,849 £67,899,102 £72,424,423 £77,433,786 £82,687,150

Additional Expenditure: Provision for PCQS Services £406,661 £880,325 £895,617 £911,138 £926,891Additional Expenditure: Practice Support / Premises and Infrastructure Reserve

£0 £250,000 £250,000 £250,000 £250,000 £250,000

GP Improved Access Not Covered by Allocation

Savings to be Identified -£2,328,427 -£3,697,039 -£5,348,923 -£6,850,041

Total Planned Expenditure £59,145,680 £62,443,510 £66,701,000 £69,873,000 £73,246,000 £77,014,000Planned Expenditure versus Allocation -£1,663,319 -£1,169,490 £0 £0 £0 £0

Notes:Revsion to GMS Costs not reflected in allocation £698,226 £717,776 £735,721 £756,321

Revision to ARRS not reflected in allocation £1,384,994 £2,649,998 £3,146,258 £4,170,994

Savings to be identified if allocation meets additional costs from GMS and ARRS update -£245,207 -£329,265 -£1,466,944 -£1,922,726

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2.5 Information Sources

Investment and evolution: A five-year framework for GP contract reform to implement The NHS Long Term Plan - https://www.england.nhs.uk/wp-content/uploads/2019/01/gp-contract-2019.pdf

Implementing the 2019/20 GP Contract - https://www.england.nhs.uk/wp-content/uploads/2019/03/implementing-the-19-20-gp-contract-changes-to-apms-pms.pdf

Additional Roles Reimbursement Scheme (ARRS) Guidance - https://www.england.nhs.uk/publication/network-contract-directed-enhanced-service-additional-roles-reimbursement-scheme-guidance/

Update to the GP Contract Agreement - https://www.england.nhs.uk/wp-content/uploads/2020/03/update-to-the-gp-contract-agreement-v2-updated.pdf

3.0 2019/20 Risks

3.1 QOF

QOF achievement in 2018/19 across West Kent was 94.7%. There is a risk exposure of £320,000 if the level of achievement reaches 100% ahead of that forecast in the forward investment plan.

3.2 Premises

A number of long-outstanding rent reviews could give rise to an estimated £300,000 cost pressure.

4.0 Summary

4.1 2019/20

Whilst there are still risks relating the 2019/20 position (section 3), further downward revisions to anticipated outturn for QOF, ARRS and premises development fees will lead to a likely under-spend of c. £1m.

4.2 2020/21 to 2023/24

The longer-term financial position between 2019/20 and 2023/24 is such that savings will need to be identified for each year in order to maintain a breakeven position.

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https://www.england.nhs.uk/wp-content/uploads/2019/01/gp-contract-2019.pdf

https://www.england.nhs.uk/wp-content/uploads/2019/01/gp-contract-2019.pdf

https://www.england.nhs.uk/wp-content/uploads/2019/03/implementing-the-19-20-gp-contract-changes-to-apms-pms.pdf



https://www.england.nhs.uk/publication/network-contract-directed-enhanced-service-additional-roles-reimbursement-scheme-guidance/

https://www.england.nhs.uk/publication/network-contract-directed-enhanced-service-additional-roles-reimbursement-scheme-guidance/

The updated GP contract agreement will lead to additional expenditure. Any adjustment to CCG allocation to cover this is yet to be confirmed.

Assuming that the additional costs are met, savings of £1.92m would need to be found to ensure a financial break-even by 2023/23. Alternatively, the Delegated Co-Commissioning budget would need to be augmented through access to the CCG Programme Budget.

5.0 Recommendations and Actions

5.1 It is recommended that the Primary Care Co-commissioning committee note the following;

• Financial Update and forecasts for 2019/20 being reported as at Month 11.• The Five Year Forward Investment plan and the anticipated financial pressures

over the medium to long term.• Consideration should be given with regards to how the projected spending

plans can best be managed within delegated commissioning resources.

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Date: 24/03/2020 Reporting Officer: Ruth Wells Agenda Item: 10 Lead Director: Gail Arnold Version: 1.0 Report Summary: The documents surmising the key risks (as of March 2020) within West Kent Primary. In addition it also looks at the tabling of items for the successor committee, either in accordance with programme milestones or scheduled review dates.

This is a working document and is further supplemented by conversations between current and successor membership.



All


Risks registers underpin the board assurance framework and all major changes to risks are reviewed on a bi-monthly basis


None

Resource implications: None Legal implications The Policy Book for Primary Medical Services

Primary Care Commissioning Committee: Handover to Successor Committee

This paper is for: Discussion

Recommendation: To review and discuss for the benefit of a smooth transition to the Kent and Medway PCCC.

For further information or for any enquiries relating to this report please contact: Ruth Wells ([email protected] )

Page 72 of 202


including equality and diversity assessment

(https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2016/01/policy-book-pms.pdf aims to support a consistent and compliant approach to primary care commissioning across England. It is essential that any decisions relating to primary care confirm to this guide and other statutory regulations and standard operating procedures that are in force.


Has an equality assessment been undertaken? ☐Not applicable - Gail Arnold/Priscilla Kankam


N/A


N/A

Report history: N/A

Appendices N/A

Next steps: Collation against peer handover documentation within new centralised Kent and Medway Committees function.

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Patient focused, providing quality, improving outcomes

Primary Care Commissioning Committee (PCCC) – Handover to successor organisation

March 2020

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The purpose of this document is to provide instruction to the PCCC successor committee as Clinical Commissioning Groups transition into an Integrated Commissioning System. It will help identify:

- Identification and record of any outstanding issues, supplemented by discussion continuingoutside of committee.

- Identification of associated risks- Future business; tabling of items within 20/21 PCCC Committees.

Key Risks and Mitigations PCCC0111 – Failure of Primary Care to reform the new roles and high impact changes to address workload and workforce plan.

PCCC022 – Risk of single handed practices terminating GP contract & risk of failing to adequately support any practice

PCCC024 – Failure to develop and embed new models of care including the transformation of primary care at the heart of local care

PCCC033 - As a consequence of the end of the GPSoC framework NHS England are creating a new procurement framework for GP IT systems known as GP IT Futures, the CCG has limited information on how this new framework will work and what the implications (financial and operational will be)

PCCC034 - There is an issue in the national GP2GP clinical record transfer process that moves the clinical record from one GP Practice system to another when a patient changes practice whereby large records are not transferred in full resulting in the receiving practice not having access to scanned letters. This issue only occurs where the sending practice is using the vision clinical system

Please refer to the full risk register, incorporated within the PCCC pack for further information on these risks.

Forward Planning Items for consideration beyond those typically considered to be ‘standing’.

Month (20/21) Item

April - DMC Contracts (Swale)

May - GMS Monitoring

- PCQS Phase 2(including Spirometry and Shared Care)

June -

July -

August -

September -

October -

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November - GMS Monitoring

December -

January -

February - GP Forward View, Highlight report

March - PCCC ToR review

TBC - TIAA Audit

- Practice Closures – lessons learned

- GP Online Consultation project

- Primary Care Strategy (STP – tbc)

- Primary Care Services phased into DES for April 2020 (STP – tbc)

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Date: 24 March 2020 Reporting Officer: Alison Burchell Agenda Item: 11 Lead Director: Gail Arnold Version: 1.0 Report Summary:

The GP Estates Strategy was approved by the West Kent CCG Governing Body in November 2018.

The purpose of this report is to provide key updates and progress regarding the identified priorities along with any new priorities. The report also now reflects Primary Care Networks with the growth and priorities aligned accordingly.

FOI status: This paper is disclosable under the FOI Act;


A. Implementation of Mapping the Future BlueprintB. Service quality and patient safetyC. Sustainable finances


Strategic Goal A&C: Failure to make the strategic changes needed to deliver Mapping the Future and the Sustainability and Transformation plan (STP) may result in a local healthcare system that

- is unsustainable in the long term- is unable to ensure high quality accessible services forlocal people- does not deliver improved outcomes and reducedInequalities


As described in the CCG’s General Practice Premises Development Policy it is inevitable that the number of proposals from practices wishing to replace and/or improve their premises will exceed the financial support available. The CCG has in place a robust process to consider premises development proposals through the 3 stage

General Practice Estates Strategy – Update


Recommendation: The Primary Care Commissioning Committee is asked to note the progress and update regarding the GP Estates Strategy.

For further information or for any enquiries relating to this report please contact: Alison Burchell, Programme Director- Primary Care Strategic Planning

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review and approval process detailed in the Premises Development Policy.

The GP Estates Strategy has been developed in discussion with each PCN and provides a priority framework for premises development to respond to growth in population. The Strategy is informed by the district and borough council local plan housing growth.

Resource implications: There are no immediate resource implications in relation to this document.

The strategy does not provide a detailed financial analysis or affordability assessment as the plans to respond to growth will be a mixture of expanding existing premises and a requirement for new premises in some areas, the detail of which is to be developed as individual business cases are progressed

The forward investment plan for recurrent premises costs is informed by estimated costs for the key premises priorities. This will continue to be reviewed and refreshed to reflect more informed costs as individual schemes are developed.

Legal implications including equality and diversity assessment

None


Has an equality assessment been undertaken?

The CCG duties will continue to be undertaken through assessment of individual premises development business cases at the appropriate points in time.

GP Contractors will be required to complete an Equality Analysis as part of any proposals progressed through CCG governance.


None. Any conflicts of interest will be identified and managed as required.


Engagement and consultation (as required) will be undertaken linked to individual practice proposals as they are taken forward (core requirement of premises development process).

Report history: GP Estates Strategy - PCCC December 2018

Appendices None

Next steps: Continued review and development of plans for identified priorities.

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Patient focused,

providing quality,

improving outcomes

General Practice Estates Strategy – Update

DATE: March 2020

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Page 2 of 29

Content 1 Introduction and purpose ............................................................................................................. 3

2 National context ............................................................................................................................ 3

3 Funding, affordability and value for money .................................................................................. 4

4 Population growth ......................................................................................................................... 5

5 Planning for growth ....................................................................................................................... 5

6 GP Premises baseline data ............................................................................................................ 6

7 Local picture and priorities ............................................................................................................ 7

8 Communications and engagement ............................................................................................. 29

9 Summary...................................................................................................................................... 29

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1 Introduction and purpose

1.1 The GP Estates Strategy was approved by the West Kent CCG Governing Body in November 2018.

1.2 The strategy defined the priority areas for general practice premises development in order to support the obligation to secure provision of primary medical services for the population of west Kent. The strategy focuses planning for population growth and the impact on general practice premises.

1.3 The purpose of this report is to provide key updates and progress regarding the identified priorities along with any new priorities. The report also now reflects Primary Care Networks with the growth and priorities aligned accordingly.

1.4 It is not the purpose of this report to provide all of the contextual information included in the 2018 GP Estates Strategy. For ease of reference the GP Estates Strategy can be found in the West Kent CCG Governing Body papers for November 2018.

2 National context

GP Contract and Workforce

2.1 The NHS Long Term Plan was published on 7 January 2019 and recognises that community health services and general practice face multiple challenges – with insufficient staff and capacity to meet rising patient need and complexity. GPs are retiring early and newly-qualified GPs are often working part-time. Use of locum GPs has increased and there is shortage of practice and district nurses. The traditional business model of the partnership is proving increasingly unattractive to early and mid-career GPs.

2.2 The NHS Long Term Plan details the commitment to increase investment in primary medical and community health services as a share of the total national NHS revenue spend across the five years from 2019/20 to 2023/24.

2.3 Linked to this investment a new five year contract for general practice was the first major pillar of the NHS Long Term Plan approved by NHS England on 31 January 2019. This will see billions of extra investment for improved access to general practice and expanded services. This is the biggest reform of GP services for 15 years and creates more certainty around funding and looks to reduce pressure and stabilise general practice.

2.4 An update to the five year agreement was published in February 2020 and enhances the five year contract agreement.

2.5 For the average PCN in 2020/21 the agreement will mean around an additional 7 full time equivalent (FTE) staff rising to 20 FTE staff in 2023/24. Within the context of the GP Estates Strategy capacity within GMS space is required for these staff and assessments will continue with PCNs in order to inform further premises priorities where required.

2.6 In addition, training practices require space for trainees. For GP trainees they should ideally have their own consulting room and where possible these should be located as close to the GP Trainer as possible to support communication and support for the trainee. With more practices looking to expand training capacity or become training practices the need to expand and re-configure existing space is vital. Providing the right environment

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https://www.westkentccg.nhs.uk/about-us/publications/?categoryesctl10652175=9727&ignoreeveryonegroup=0&assetdet1a5cc360-7091-42ae-8890-a825dc169160=469554&search=GB+2018&categoryesctl1a5cc360-7091-42ae-8890-a825dc169160=9727&searchcontent=1&p=4

https://www.longtermplan.nhs.uk/

https://www.england.nhs.uk/gp/gpfv/investment/gp-contract/

https://www.england.nhs.uk/wp-content/uploads/2020/02/update-to-the-gp-contract-agreement-2021-2324.pdf

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through training will support practices to increase the likelihood of retaining staff once they are qualified.

Sustainable Development

2.7 The NHS Long Term Plan includes commitments regarding environmental sustainability in the NHS.

2.8 With regards to new buildings, since 2008 the Department of Health require that as part of outline business case approval that all new builds of capital costs in excess of £2million achieve an ‘Excellent’ and all refurbishments achieve a ‘Very Good’ rating under BREAAM Healthcare (Building Research Establishment Environmental Assessment Method).

2.9 The BREEAM assessment is focused on an asset’s environmental, social and economic sustainability performance, using standards developed by BRE. This means BREEAM rated developments are more sustainable environments that enhance the well-being of the people who live and work in them and help protect natural resources.

2.10 Additionally all projects will need to achieve a credit in relation to a Travel Plan. This demonstrates consideration being given to accommodating a range of travel options for building users, thereby encouraging the reduction of reliance on forms of travel that have the highest environmental impact.

2.11 Energy efficiency and reduction in carbon footprint is something that all GP Contractors should be encouraged to consider in order to support delivery of the NHS commitments regarding environmental sustainability; whether premises are owner-occupied or leased.

3 Funding, affordability and value for money

3.1 General Practice premises development, whether providing additional capacity from an existing facility or through a new facility, will have funding consequences both in terms of capital build costs and ongoing revenue costs (primarily through the re-imbursement of rent, rates and water rates).

3.2 The revenue is the responsibility of the CCG within the primary care co-commissioning budget. The GP contractor, under their contract, is required to provide suitable and compliant premises from which to deliver services and is responsible for sourcing capital for improvements and developments.

3.3 The delegated co-commissioning budget for WK CCG in 2019/20 is £63.613m; of this £6.447m (10.13%) is budgeted for premises (rent and rates re-imbursements).

3.4 This strategy does not provide a detailed financial analysis or affordability assessment as the plans to respond to growth will be a mixture of expanding existing premises and a requirement for new premises in some areas, the detail of which is to be developed as individual business cases are progressed

3.5 The forward investment plan for recurrent premises costs is informed by estimated costs for the key premises priorities. This will continue to be reviewed and refreshed to reflect more informed costs as individual schemes are developed.

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4 Population growth

4.1 There are nine Primary Care Networks (PCNs) in west Kent covering populations of between 33,768 and 82,271, with a total west Kent registered population of 503,2191 (as at 1 January 2020). In the past three years across all nine PCNs there has been (Jan 2017 – Jan 2020):

4.2 Since January 2017 there have been some mergers and practice closures. Dispersal of patient registrations has not always been within the same PCN area and this has led to some of the variation in list sizes.

4.3 The four district and borough councils are at different stages of local plan development to cover periods up to between 2031 and 2037. It is therefore important to recognise that much of process remains iterative and strategies for general practice premises will continue to be assessed and further developed as the development of Local Plans progress.

5 Planning for growth

5.1 Following the initial ‘Planning for Growth’ meetings has been held with each of the original seven clusters of general practices (prior to PCNs) in 2018 work has taken place to review and refresh priorities; this has been linked directly to development of plans and key updates in council local plans.

5.2 All discussions continue to be set in the context of the CCG’s obligation to secure provision for primary medical services and are focused on understanding the ambitions of existing general practices to expand to support the expected growth in population and the requirements from a premises perspective. Understanding the position of practices continues to be an important part of the discussions in order to understand whether the growth could be managed by existing practices or whether the CCG will be required to commission additional primary medical services in specific areas.

5.3 The analysis of the council local plan housing supply information has been taken at a point in time and will change as the local plans are further developed and finalised. The actual number of dwellings on a site may change following detailed consideration of a planning application and there will continue to be ‘windfall’ developments that include conversion of existing buildings and redevelopment of small plots which are not fully accounted for in the CCG analysis. The information has however allowed the CCG to undertake an assessment with each area in relation to the key areas of growth to inform the priorities for premises development.

5.4 The planned housing developments will not be distributed equally across all practices; there are a number of large strategic sites that have an impact in a specific PCN area and

1 Raw patient list size (not weighted)

Registered patient list increase of

18,954 (3.9%)

Patient list variation in each PCN of

between -2.2% and +8.8%

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there is also the cumulative impact of smaller developments within an area that needs to be considered when assessing growth.

5.5 The growth information presented in this strategy is a high level analysis of housing supply information undertaken by the CCG and is intended to give an indication of growth in a PCN area for planning purposes only. It is important to recognise that the information details expecting housing trajectories for a given period and patient registrations are unlikely to follow the same phasing as sales of houses will vary to the development profile and patients don’t necessarily register with a general practice when they move into a new house. The overlap between practice and PCN boundaries also means that flows will be influenced by patient choice.

5.6 The analysis is mainly focused on developments with more than 20 dwellings on a site. It is therefore recognised that smaller developments will continue to take place and windfall sites (sites that become available unexpectedly and not allocated in a local plan) will also impact. This however is balanced by the fact that the expected phasing for some sites in the current analysis may differ due to the timing of planning decisions and actual delivery trajectories.

6 GP Premises baseline data

6.1 The NHSE General Practice Premises Policy review undertaken last year outlined that there was no consistent system wide understanding in relation to primary care estate data. The collection of a comprehensive data set for primary care was approved as a work stream to be taken forward.

6.2 Kent & Medway CCGs are within the pilot wave of the national programme due to commence in April 2020.

6.3 The programme of work will focus on a baseline of consistent data being collected for every NHS reimbursed general practice across England and then a nationally agreed process and methodology for this to be maintained at a local level will be devised.

6.4 The data collection will involve submission and validation of data already held by CCGs along with a site based survey at each practice.

6.5 The CCG and practices already have a good understanding of the local general practice premises picture and the baseline data will provide up to date objective and consistent data to inform continued development of local priorities. The baseline data will also form a recognised evidence base as part of business cases for premises development, regardless of capital funding route.

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7 Local picture and priorities

7.1 Primary Care Network Overview

7.2 There are nine Primary Care Networks within WK CCG formed of 54 general practices. There is one practice within the CCG that is not a member of a PCN; local arrangements are in place with South Maidstone PCN to provide network service coverage to the registered population.

7.3 The following PCN focused sections of the plan provide an overview for each PCN along with the priorities for premises development responding to the expected growth in population.

7.4 Maidstone area

7.5 There are five PCNs that fall within the Maidstone Borough Council area; South Maidstone, Maidstone Central, ABC, The Ridge and The Weald.

7.6 ABC and Maidstone Central PCNs also falls within the Tonbridge and Malling Borough council area and The Weald PCN also falls within the Tunbridge Wells Borough Council area.

7.7 The following graphics provide an overview and map for each PCN in the Maidstone Area (excluding the Weald PCN).

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Using the council housing supply information the estimated housing and population growth can be summarised as below for ABC, Maidstone Central, South Maidstone and The Ridge PCNs:

2019/20 – 2023/24

2024/25 – 2028/29

Total

Maidstone Borough Council - Dwellings2 ( >=20 per site)

4,655 1,978 6,633

Maidstone Borough Council – Dwellings3 (<20 per site)

841 0 841

Est. population growth (using 2.34 average

occupancy) 12,860 4,628 17,488

Tonbridge & Malling Borough Council - Dwellings 4 ( >= 20 dwellings)

132 0 132

Tonbridge & Malling Borough Council New Local Plan5

370 750 1,120


occupancy) 1,175 1,755 2,930

TOTAL DWELLINGS 5,998 2,728 8,726

TOTAL EST. POPULATION GROWTH 14,035 6,383 20,418

2 MBC Housing supply information at 1 April 2019 3 MBC Housing supply information at 1 April 2019

4 TMBC Housing supply information at 1 April 2019(sites >=20 dwellings) 5 TMBC Housing Trajectories New Local Plan – Reg 22 submission

Estimated growth

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The above excludes growth in the Weald PCN area; this is detailed in the Weald PCN section of this document.

The overlap between a large number of practice boundaries means that individual housing developments fall within a number practice and PCN boundaries; it is not therefore possible to accurately reflect potential growth at a PCN level as patients have the choice to register at the different practices.

The population growth detailed above is summarised below to show the growth that falls within each PCN area as follows (noting this means the growth is counted more than once):

PCN Estimated population growth within PCN boundary - 2019/20 – 2023/24 (sites >=20 dwellings)

Of this population growth the amount of growth that only falls within the single PCN area

ABC 3404 0

Maidstone Central 9428 220

South Maidstone 7368 0

The Ridge 4719 1626

It is however important to note that existing practice boundaries are influencing and overstating the picture regarding growth for each PCN. This is because some practice boundaries cover a wide area but patient registrations are centred within specific areas and not to the full extent of their boundaries. It should therefore be acknowledged that whilst choice exists it will be unlikely in some cases that new registrations would flow from specific developments to a PCN area for this reason. Maidstone Central PCN in particular is overstated due to one large practice boundary; this can be seen in the maps above.

To summarise from a geographical perspective the most significant areas of growth in the next five years are (summarised from sites with >=20 dwellings):

Centre of Maidstone – c1260 dwellings / c2950 population

Langley/Sutton Road area – c 930 dwellings / c 2176 population

Coxheath (and surrounding area) – c 500 dwellings / c 1170 population

Headcorn - c 340 dwellings / c 795 population

Lenham c 310 dwellings / c 725 population

In addition to the housing supply figures above Lenham is identified in the current MBC Local Plan as a broad location for housing growth for the delivery of approximately 1000 dwellings up to 2031. This is further considered in the Regulation 14 consultation of the Lenham Neighbourhood Plan (consultation period ends 27 March 2020).

Is the growth across the cluster or in specific areas?

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Mapping has been undertaken to assess existing planning permissions and allocations (expected developments) and the practice boundaries that these fall within; this has been shared with practices.

The Maidstone Borough Council Local Plan Review commenced in 2019 and is expected to increase the number of new dwellings per annum from 883 to 1236 dwellings per year. The priorities in this strategy will be reviewed and refreshed once more detailed information is available regarding proposed areas of growth; however some general assumptions are already being made when considering new GP premises developments.

The Tonbridge and Malling new Local Plan (Reg 22 submission) details a strategic site in South Aylesford for c1000 dwellings; an application has already been made for c800 houses on this site. Based on housing trajectory information in the draft local plan delivery on this site could be expected from 2022/23 should permission be granted. This development falls within the existing boundaries of 2 practices in the ABC PCN and 1 practice in Maidstone Central.

Within The Ridge PCN two practice boundaries also extend in the Ashford Borough Council area. A previous analysis highlighted a very small amount of development within the practice boundaries (c 100 dwellings). As with other areas this will continue to be reviewed when updated information is available.

The below table provides an update against the priorities identified in the November 2018 GP Estates Strategy.

Priority (Nov 2018) Update (March 2020) Primary Care Network

College Practice (largest practice in area with c. 19,500 list) have signalled an intention to support future growth in the area and will therefore require a premises development plan in order to provide sustainable and resilient capacity . Two of the existing premises (main and one branch site) are not considered suitable for longer term with little capacity to accommodate growth. Options should also include understanding opportunities through the next stage of Local Care Hub development for the Maidstone area.

Stage 1 Premises Development plan for Allington (branch surgery) supported by PCCC in June 2019. Work to develop options underway.

No plans progressed for main site. To be considered linked to proposal for Allington branch, commitment for a new general practice building in the centre of Maidstone and Local Care Hub options.

ABC

Aylesford Medical Centre will require a premises development plan as the current site cannot be extended or reconfigured further and will not accommodate the growth generated from the strategic site. Options should include understanding opportunities through the next stage of Local Care Hub

To be assessed once outcome of planning decision for strategic site (South Aylesford – TMBC) is available.

ABC

Priorities

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development for the mini-hub in the Aylesford area and opportunities linked to a doctor’s surgery on the strategic site.

The Shepway Medical Centre requires a premises plan (new site) for the branch surgery at Grove Green. The Practice has signalled their intention to support future growth.

Stage 1 Premises Development plan supported by PCCC in December 2019. Work to develop options underway.

Maidstone Central

A plan to address the one poorer quality building (Grove Park Surgery) to be developed.

The building is no longer in use following a merger with The Medical Centre Group (Northumberland) in October 2019.

Maidstone Central

Greensands premises development to be progressed through CCG governance. It is expected that this development could provide capacity to accommodate growth in Coxheath and the surrounding area for the future. (Note that premises development cases are not fully supported or signed off until Stage 3 of the process)

Stage 2 Outline Business Case was approved by PCCC in October 2019. Work continues to progress the full business case for Stage 3.

South Maidstone

Growth in the Langley area (Sutton Road) will require a premises development plan due to the significance of the growth; c 2500 registrations from 5 main developments in the next 5 years with a further c2000 in the following 5 year period. As the area is covered by more than one practice boundary a plan should be developed with one or more interested practices supported by the CCG.

Sutton Valence Group Practice premises development proposal supported by PCCC in April 2019. Proposal details move to single building at new site (to be identified) and provision for growth in the Sutton Road/ Langley / Otham area. Work is underway to identify options.

The Ridge

Headcorn Surgery is located in new purpose built premises (c 5 years old). It is expected that the future growth can be accommodated through utilisation of space not currently used; this may require re-configuration of existing space to ensure optimum use.

Discussions held between practice and CCG. Practice has not identified an immediate need to progress any plans.

The Ridge

Len Valley Practice covers the areas of Lenham and Harrietsham (and wider) and will require a premises development plan in order to accommodate the expected growth (c 1000 registrations) in the current local plan. Any plan should ensure maximum efficiency and utilisation working across both the main and branch sites and should include planning for the potential c1000 additional dwellings as

Practice commissioned feasibility piece of work (S106 funded) to identify options for potential reconfiguration and expansion at one or both sites to support growth. The potential options will inform continued discussions between the Practice and CCG; this will include ensuring consideration

The Ridge

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recently consulted in the Lenham Neighbourhood Plan.

of any additional growth arising from the MBC Local Plan Review.

Headline growth figures linked to the review, along with continued growth from the current local plan, would indicate the requirement for a new general practice to be commissioned in the Maidstone Central cluster area. A proactive approach is proposed to the commissioning of this capacity to support future growth.

The requirement for a new general practice building in the centre of Maidstone remains a priority. It had been agreed that strategically this requirement could potentially align to the location of the Local Care Hub in Maidstone once confirmed.

Discussions regarding the next steps will commence with local practices in the first instance. The opportunity to align to the Local Care Hub (i.e. co-location) once confirmed remains.

PCN alignment to be informed by next stage of work.

Ensure maximum utilisation of the four newer purpose built premises through an aligned workforce and service strategy at practice and cluster level (for example including both space for primary medical services and cluster level services) to ensure a proportion of growth can be accommodated.

All premises supporting primary medical services and PCN services.

All

Utilise available S106 healthcare contributions to support reconfigurations within existing premises to maximise use of clinical space where possible; including off site / digital solutions for patient notes (that create clinical space).

Some premises and IT related projects have been supported by S106 in agreement with Maidstone Borough Council. Proposed alignment of available S106 (within spend dates) to new premises developments shared with MBC.

Identifying opportunities for the relocation of administrative and storage functions off site to enable the creation of additional clinical space; conversion of rooms currently used for notes storage will be considered in line with the national approach to digitise Lloyd George Paper records by 2022/23.

All

Work with Maidstone Borough Council as part of the Local Plan review (due to commence in spring 2019) to understand and assess the impact of potential further areas of growth across the cluster area.

Local Plan review has commenced and CCG is fully engaged.

All

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7.8 Malling PCN

All practices within the Malling PCN fall within the Tonbridge and Malling Borough Council area.

Using the housing supply information from the current local plan and trajectories from future local plans the estimated housing and population growth can be summarised as follows:

2019/20 – 2023/24

2024/25 – 2028/29

Total

Tonbridge & Malling Borough Council - Dwellings 6

1,545 0 1,545


occupancy) 3,615 0 3,615

Tonbridge and Malling – Draft new Local Plan7

865 1,208 2,073


occupancy) 2,024 2,827 4,851

TOTAL FOR PCN - dwellings 2,410 1,208 3,618

TOTAL FOR PCN – population growth 5,639 2,827 8,466

6 TMBC Housing supply information at 1 April 2019

7 Housing trajectories in the New TMBC Local Plan

Estimated growth

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The majority of the growth in the next five years arises from developments as follows:

Peters Village Wouldham (840 dwellings/1965 population)

Kings Hill, West Malling (414 dwellings/ 968 population).

The new Tonbridge and Malling Borough Council Local Plan (up to 2031) is currently at examination stage. The draft plan details five strategic sites two of which are in the Malling area; Bushey Wood, Eccles (900 dwellings in Phase 1) and Broadwater Farm, North of Kings Hill (900 dwellings).

The majority of the expected growth arising from the new Local Plan is linked to the two strategic sites detailed above along with East Malling where c. 457 dwellings are detailed (of which 421 are aligned to 2 large sites).

In order to respond to growth within the next five years and plan for future years the priorities are:

Priority (Nov 2018) Update (March 2020)

Phoenix premises development to be progressed through CCG governance. This development should ensure capacity to accommodate growth in Wouldham and the future strategic site at Eccles. (Note that premises development cases are not fully supported or signed off until Stage 3 of the process)

Stage 2 Outline Business Case was approved by PCCC in December 2019. Work continues to progress the full business case for Stage 3.

A premises development to accommodate growth in the Kings Hill/ West Malling area will be required. Both West Malling Group Practice and Wateringbury Surgery have signalled an intention to support growth in this area (estimated c2600 patient registrations in next five years with c1600 estimated registrations in the following five years).

The West Malling Group Practice are in the early stages of strategically assessing the premises development requirements and potential options for longer term delivery of services that respond to the growth in the population. In the short term some changes at the Kings Hill premises will create one additional clinical room.

Reconfiguration at both the Wateringbury

Long term strategic assessment to be undertaken.

Expansion and reconfiguration at Queen Street, Kings Hill site completed. Relocation of West Malling site to Queen Street, Kings Hill completed March 2020.

Reconfiguration works completed in 2019

Is the growth across the PCN or in specific areas?

Priorities

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Surgery main and branch sites will enable the creation of two additional clinical rooms. In the longer term the premises at the main site could be considered for expansion to support continued growth in the area.

(S106 contribution approved by TMBC).

Thornhills Medical Practice (second largest practice in cluster with c 14,000 list) has signalled an intention to support future growth of c1000 registrations in the East Malling area. To support this a premises development plan should be considered in order to provide capacity through reconfiguration of the existing premises.

Work underway to inform reconfiguration and expansion requirements at existing premises. PCCOG supported principles and next steps in February 2020.

A review of capacity at Snodland Medical Centre should be undertaken to ensure growth of c900 registration from the existing developments can be accommodated within existing premises.

Initial review undertaken in 2019 - limited growth in patient list in past 3 years (1.1%) with small amount of growth expected from current housing development.

To be kept under review linked to practice workforce model and wider PCN requirements.

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7.9 Sevenoaks PCN

All practices within the Sevenoaks Cluster fall within the Sevenoaks District Council (SDC) area, with the exception of Borough Green Medical Practice that falls within the Tonbridge and Malling Borough Council (TMBC) area.

Using the housing supply information and Local Plan information the housing and population growth can be summarised as follows:

2019/20 – 2023/24

2024/25 – 2028/29

Total

Sevenoaks District Council - Dwellings 8 1,667 1,031 2,698

Est. population growth (using 2.34 average occupancy) 3,901 2,413 6,314

Tonbridge & Malling Borough Council - Dwellings 9 94 0 94

Tonbridge and Malling – Draft new Local Plan10 0 1,080 1,080

Est. population growth (using 2.34 average occupancy) 220 2,527 2,747



8 CCG analysis of April 19 Sevenoaks District Council Local Plan Submission Version 9 TMBC Housing supply information at 1 April 2019

10 Housing trajectories in the New TMBC Local Plan(submission version)

Estimated Growth

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Within the Sevenoaks District Council area the most significant areas of growth based on deliverable sites in the Local Plan in the next five years are (included sites with permission):

Edenbridge (724 dwellings/ 1694 population)

Halstead & Badgers Mount (195 dwellings/ 456 population)

Sevenoaks Urban Area (448 dwellings/ 1048 population) From 2024/25 the most significant areas of growth are:

Halstead (350 dwellings/ 819 population)

Sevenoaks Urban Area (566 dwellings/ 1324 population)

Edenbridge (115 dwellings/ 269 population) The Sevenoaks Urban Area is covered by four practice boundaries. Of note outside of the above analysis is that a planning application has been made for a large site in the northern area of Sevenoaks; this is for c850 dwellings and a retirement village. The CCG is currently assessing the impact of this with general practices as part of planning for future growth. A report has recently been issued to Sevenoaks District Council by the Planning Inspector that concludes the Sevenoaks District Council Local Plan is not legally compliant in respect of the Duty to Co-operate (DtC) and it has been recommend that the Plan is not adopted. The analysis in this report has been informed by the housing development information in the submitted version of the Sevenoaks Local Plan. The CCG will review and refresh the analysis as required. Within the Tonbridge and Malling Borough Council area the significant area of growth is the strategic site in Borough Green where the housing trajectory details 1720 of the 2100 dwellings being delivered in the local plan period (to 2031); although at this time it is noted that delivery is not expected within the next five years. The council has established a strategic working group for this site. In order to respond to growth within the next five years and plan for future years the priorities are:


Development of new premises in Edenbridge to replace hospital and existing GP premises as agreed following consultation in 2017. This development should ensure capacity to accommodate growth within the Edenbridge practice boundary.

Plans are being progressed through joint project with KCHFT. GP element of scheme to be submitted for review in line with premises development policy during 2020.


Priorities

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Undertake a review of capacity and growth across the central Sevenoaks practices to in order to understand any gap to accommodate future growth and to what extent the current reconfigurations, expansions and refurbishments will close the gap.

Amherst extension completed late 2019. South Park refurbishment completed February 2020. Town – to be considered through CCG governance. Proposal for discussion/ review linked to above.

Otford Medical Practice covers the main northern area and plans for reconfiguration at the main site and an extension at the branch are in place supported through S106 developer contributions and NHS minor improvement grant. The northern area of Sevenoaks will see a high level of growth and an assessment will be required once the final local plan and potential phasing of development is known in order to understand whether additional capacity will be required at a point in the future.

Otford reconfiguration / creation of 1 additional clinical room completed early 2019. Kemsing Phase 1 extension – commenced early 2020 (2 new clinical rooms)

Kemsing Phase 2 – to be considered as part of strategic assessment of capacity/growth linked to Local Plan and decisions regarding a large planning application.

Based on the phasing in the draft local plan the growth at the strategic site at Borough Green is not expected to start until 2026/2027 (depending on commencement of occupation). Given the significant development in this area premises development plan options for Borough Green Medical Practice will need to be explored at an early stage as part of the master plan obligation to ensure provision for healthcare to meet the needs of the development.

Working group established by TMBC in relation to the Strategic Site (early 2020).

Opportunities may exist through the next stage of Local Care Hub development for the Sevenoaks area; these should be explored as the work progresses.

To be considered at point Local Care Hub work reports.

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7.10 Tonbridge Cluster

Note – Difference in numbers of premises listed vs map is due to one practice having two premises in same location

Using the annual monitoring and local plan information from both councils the expected growth can be summarised for the PCN as follows:

2019/20 – 2023/24

2024/25 – 2028/29

Total

Tonbridge and Malling Borough Council - Dwellings with permission11

226 0 226

Tonbridge and Malling Borough Council – Dwellings12 - New Local Plan (submission version at examination stage)

940 479 1,419


occupancy) 2,728 1,120 3,848

Tunbridge Wells Borough Council – Dwellings13 with planning permission(>=20 dwellings per site)

819 169 988

Tunbridge Wells Borough Council – Dwellings14 - new Local Plan (>= 20 dwellings per site)

0 2,381 2,381

Est. population growth 1,916 5,967 7,883



11 Monitoring information at April 2019 12

Housing trajectories in the New TMBC Local Plan(submission version) 13 CCG analysis of TWBC Draft Local Plan (Reg 18) Allocations and Extants list - Paddock Wood & Tudeley areas only 14 CCG analysis of TWBC Draft Local Plan (Reg 18) Allocations and Extants list – Paddock Wood & Tudeley areas only

Estimated growth

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All practices within the cluster fall within the Tonbridge and Malling Borough Council area, with the exception of Woodlands Health Centre that falls within the Tunbridge Wells Borough Council area. The new Tonbridge and Malling Borough Council Local Plan (up to 2031 – currently at examination stage) details five strategic sites one of which is in the Tonbridge cluster titled South West Tonbridge (480 dwellings). The majority of the expected growth arising from the Tonbridge and Malling Borough Council new Local Plan for this PCN is within Tonbridge and Hadlow. The housing trajectory within the new local plan details 1,419 dwellings in the Tonbridge PCN area; with 940 estimated to be built by 2023/24 (635 of which will be in Tonbridge, 247 in Hadlow and 58 in East Peckham). The consultation on the Tunbridge Wells Borough Council draft Local Plan (Reg 18 version) was completed in 2019. The analysis of the draft plan and growth impacts have been discussed with existing general practices. In summary the significant areas of growth in the draft Local Plan are as follows:

Paddock Wood - The proposed development of c 4000 dwellings will require capacity of c 10,000 new patient registrations in general practice (c12000 when including existing permissions). Given the scale of development there will be a requirement for a new general practice premises to ensure the growth can be accommodated.

Tudeley – the proposed standalone garden settlement of 2,500-2,800 dwellings, of which 1,900 are expected to be delivered in the plan period. The growth is estimated to be c4500 new patient registrations in the plan period and c6500 in total for the development.

The CCG has been included in early discussions regarding the comprehensive approach to master planning and expects to be fully involved as this develops in order to strategically assess and identify the requirements for general practice capacity. Critical to this will be the phasing of development, availability of contributions and the timing of the delivery of required infrastructure. The existing permissions in Paddock Wood are related to 3 large sites that are under construction; this will increase the population over the next 5-7 years by approx. 2300 patients. It should however be noted that whilst Woodland Health Centre premises are within Paddock Wood there are two other practice boundaries that currently cover the area with approximately 900 patients registered from the area. Hildenborough Medical Group and Warders Medical Centre boundaries cover areas within Sevenoaks District Council and both practices have branch surgeries in the areas where very small amounts of development are planned – Sevenoaks Weald (19 dwellings) and Chiddingstone (35).


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Development of new premises for Tonbridge Medical Group. Approved in April 2018. This could accommodate the growth from the strategic site in South West Tonbridge.

Build underway - estimated completion Summer 2020

Review of capacity and growth in northern Tonbridge area to be undertaken with Hildenborough Medical Group in order to determine any premises development requirements to accommodate growth. From the draft new Local Plan, 323 of the 475 dwellings expected to be built within the Tonbridge area in the next 5 years will fall within the Hildenborough practice boundary.

Discussions ongoing as part of PCN assessment. Utilisation study required to support short/medium term.

Review of capacity and growth to be undertaken with Hadlow Medical Centre in order to determine any premises development requirements to accommodate growth.

High level discussions regarding growth taken place. Utilisation study required to inform any future requirements.

Review of capacity and growth to be undertaken with Woodlands Health Centre, Paddock Wood to determine any premises development requirements. Growth generated from the Paddock Wood area in the current local plan will require capacity for c2000 registrations in the next 5 years. Any assessment must include Howell Surgery and Yalding Surgery in the Weald Cluster as existing boundaries cover the area.

Discussions taken place regarding current growth –existing premises could support current growth (workforce considerations would be required).

Boundary changes agreed through joint discussions for Howell Surgery in the Weald; reduced area of coverage in Paddock Wood.

Opportunities may exist through the next stage of Local Care Hub development for the Tonbridge area; these should be explored as the work progresses.

To be considered at point Local Care Hub work reports.

Any growth proposed in the new Tunbridge Wells Borough Council Local Plan for the Paddock Wood area will be assessed and the priorities refreshed when the plan is consulted on in summer 2019.

Draft Local Plan analysed and reviewed with PCNs.

Priorities

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7.11 Tunbridge Wells PCN

Note – Difference in numbers of premises listed vs map is due to two practices being based in the same building

All practices within the Tunbridge Wells Cluster fall within the Tunbridge Wells Borough Council area.

Using the housing supply information from the current local plan the estimated housing and population growth can be summarised as follows:

2019/20 – 2023/24

2024/25 – 2028/29

Total

Tunbridge Wells Local Plan - Dwellings15 with planning permission(>=20 dwellings per site)

1,097 0 1,097


408 621 1,029

Total Dwellings 1,505 621 2,126


occupancy) 3,521 1,453 4,974

15 CCG analysis of TWBC Draft Local Plan (Reg 18) Allocations and Extants list 16 CCG analysis of TWBC Draft Local Plan (Reg 18) Allocations and Extants list

Estimated Growth

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With the exception of c104 of the total 1,097 dwellings with permission the growth will be within the main urban area of Tunbridge Wells (including within the boundary of Waterfield House Practice, Pembury). This means that this growth is spread mainly across the practices in and around the town centre; is not however possible to easily set out the expected flow of patients to specific practices as patients are able to choose from a number of practices due to the boundaries overlapping.

In the new Local Plan c234 dwellings are in Pembury with the remaining 795 dwellings within the main urban area of Tunbridge Wells.



St Andrews Medical Centre, Southborough premises development being progressed through NHS England Estates and Transformation Fund (ETTF) governance route. It is expected that this development could accommodate a list increase of at least c2000 patients.

ETTF funded. Full Business Case approved by NHSEI. Build commenced late 2019.

Greggs wood and Speldhurst Medical Practice premises development in Greggs wood to be progressed through CCG governance. It is expected that this development could accommodate an increase of at least c2000 patients. (Note that premises development cases are not fully supported or signed off until Stage 3 of the process)

Stage 1 proposal supported October 2018. A further options appraisal now required after initial site now not viable option.

It is clear from the current growth forecasts that significant growth is expected to continue in the main urban area and a sustainable solution is required to ensure resilience for the future. It is therefore proposed that a model to develop capacity ‘out of town’ supported by provision in and around the town centre be explored. Any model would need to address existing premises deficiencies and ensure the future growth (new local plan) is accommodated (through this model and existing practices).

Discussions have taken place between CCG and Lonsdale and CCG and Grosvenor & St James regarding future considerations. Further discussions required and opportunities explored within the context of the TWBC Local Plan and expected growth.


Priorities

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Clanricarde Medical Centre and Abbey Court Medical Centre occupy a modern premises refurbished and converted to health use in 2010. Maximum utilisation of these premises through an aligned workforce and service strategy at practice and cluster level (for example including both primary medical services and cluster level services) will ensure a proportion of growth can be accommodated. This may include premises reconfigurations.

Reconfiguration of existing space and creation of 2 additional clinical rooms at Clanricarde completed late 2019 (S106 contribution approved by TWBC).

A review of capacity and growth to be undertaken with Waterfield House Practice to determine any premises development requirements arising from the current local plan (some growth within main urban area is within practice boundary); a fuller assessment for the Pembury area will be required once details of the new Local Plan are available.

Estimated population growth c800 patients over TWBC plan period. Discussions have taken place regarding future plans to extend premises to accommodate growth and new PCN roles. Practice has submitted proposal for NHS Capital grant (currently under consideration).

Any growth proposed in the new Tunbridge Wells Borough Council Local Plan for the cluster area will be assessed and the priorities refreshed when the plan is consulted on in summer 2019.

TWBC Draft Local Plan analysis assessed with PCN Sept 2019.

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7.12 Weald PCN

Within the Weald cluster eight practices fall within the Tunbridge Wells Borough Council area and three practices within the Maidstone Borough Council area (Yalding, Marden and Staplehurst).

2019/20 – 2023/24

2024/25 – 2028/29

Total

Tunbridge Wells Borough Council – Dwellings17 with planning permission (>= 20 dwellings per site)

238 0 238


641 1651 1930


occupancy) 2056 3863 5919

Maidstone Borough Council - Dwellings19 (>=20 dwellings per site)

1019 60 1079


occupancy) 2384 140 2524

TOTAL FOR PCN - dwellings 1898 1711 3609

TOTAL FOR PCN – population growth 4441 4003 8444

17 CCG analysis of TWBC Draft Local Plan (Reg 18) Allocations and Extants list

18 CCG analysis of TWBC Draft Local Plan (Reg 18) Allocations and Extants list 19 MBC Housing supply information at 1 April 2019

Estimated growth

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Within the Maidstone Borough Council area the growth is summarised by area as follows (dwellings/population growth): Marden (324/758), Staplehurst (632/1479) and Yalding (123/287).

As detailed in an earlier section the Maidstone Borough Council Local Plan review commenced in 2019. The priorities will be reviewed and refreshed once more detailed information is available regarding proposed areas of growth.

The new Tunbridge Wells Borough Council Local Plan details development in a number of areas in the next 10 years. The majority and more significant being in Hawkhurst (421 dwellings), Cranbrook (627), Horsmonden (208), Matfield (108) and Sissinghurst (83).

Whilst the Paddock Wood growth has been reflected in the Tonbridge PCN section it should be noted that the existing boundaries of Howell Surgery and Yalding Surgery cover part of the Paddock Wood area.



Marden Medical Centre has signalled an intention to support growth in this area. A premises development plan would be required to accommodate the estimated growth of c1000 people in the next five years.

Discussions ongoing between CCG and Practice regarding potential options; consideration being given to the MBC Local Plan Review.

Staplehurst Health Centre has capacity to accommodate growth due to the building not being fully utilised. A review should be undertaken to determine requirements. The health centre is owned by NHS Property services and the wider priority must therefore be to ensure full utilisation of the building including cluster wide services.

No specific discussions/ action progressed – to continue to be considered as part of PCN planning.

Yalding Surgery has capacity to accommodate the expected growth from the immediate area. Consideration will be given to the potential impact of growth from the Paddock Wood area once the wider assessment referred to above has been undertaken.

The practice continues to have capacity for the growth in the immediate area. Longer term (as part of new TWBC local plan) consideration will specifically linked to Paddock Wood and the practice boundary.

North Ridge Medical Practice and Wish Valley Surgery premises are not considered suitable

Stage 1 Premises Proposal supported by Primary Care Commissioning Committee –


Premises

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for the longer term with North Ridge premises being a poorer quality converted building. The two practices have c10,300 registered patients and have signalled their intention to merge and re-locate to a new site (one premises); initial scoping work has been undertaken and the practice intends to submit a premises development proposal. A premises development in this area must accommodate future growth in the area and a full assessment should be undertaken once the new Tunbridge Wells Local Plan is available.

April 2019.

Preferred site confirmed and in TWBC Local Plan. Communications and engagement continuing. Work continues to progress the outline business case for Stage 2.

Orchard End Surgery, Old School Surgery and The Crane Surgery in Cranbrook occupy premises that are not considered suitable for the longer term; with Orchard End premises being a poorer quality converted building. The three practices have c8500 patients registered and have signalled their intention to merge and relocate to one site (new premises). A premises development in this area must accommodate future growth in the area and a full assessment should be undertaken once the new Tunbridge Wells Local Plan is available.

Stage 1 joint premises proposal expected to be considered at October 2019 CCG Primary Care Commissioning Committee.

Preferred site confirmed and in TWBC Local Plan. Work commencing on preferred site in order to progress the outline business case for Stage 2.

Howell Surgery delivers services from the main site at Brenchley and a branch surgery in Horsmonden; the branch site is a poorer quality converted premises. The practice is running at capacity across both sites with a list of c5000 patients. The expected growth of c170 patients (74 dwellings) from the current local plan along with potential flows from Paddock wood will put pressure on the practice. At this stage the CCG is working on the basis that the new council local plan will propose additional development within this area of the weald and a full impact assessment will be undertaken once the plan is available; this would include Lamberhurst Surgery and Old Parsonage Surgery, Goudhurst as boundaries overlap.

Boundary change agreed following joint discussions with other practices; reduced coverage in Paddock Wood area.

Assessment of growth continues to be undertaken linked to draft TWBC Local Plan (Reg 18) . Strategic planning discussions recommenced in this area.

Opportunities may exist through the next stage of Local Care Hub development in relation to a min-hub in the Weald area; this should be explored as the work progresses.

Engagement in hub work has taken place. To be considered at point Local Care Hub work reports.

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8 Communications and engagement

8.1 The GP Estates Strategy provides an overarching framework and priorities for premises development. Communication and engagement activities will be undertaken by general practices for all plans that involve a new premises development (i.e. change in site/location). Patient and stakeholder engagement activities are a key requirement of any premises development business case.

8.2 A best practice user guide for communication and engagement activities specifically related to general practice premises changes was developed in 2019 to support practices.

9 Summary

9.1 This report provides an update for the west Kent CCG area including the PCN picture and premises priorities to accommodate the potential growth. Delivery proposals and plans will continue to be developed in order to facilitate the required increase in premises capacity.

9.2 As referenced in the strategy developing premises capacity is not an isolated strand of work and must be fully connected to the wider general practice programme of the NHS Long Term Plan focusing on areas such as workforce, care models, workload and technology.

9.3 It is important that the principles and priorities detailed within the GP Estates Strategy are fully understood and recognised within the local health and care system as part of the wider strategy. The GP Estates Strategy will be shared through the West Kent Integrated Care Partnership.

9.4 The CCG will continue to work closely with general practices and PCNs to support development of the proposals and plans.

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Date: 24/03/2020 Reporting Officer: Ruth Wells Agenda Item: 12 Lead Director: Gail Arnold Version: 1 Report Summary:

Work has been carried out to align the Section 96 processes across the 8 Clinical Commissioning Groups (CCGs). Section 96 payments (sometimes referred to as discretionary payments or funding locally) are a legacy from the NHS Act 2006, which provided Primary Care Trusts (PCTs) with the facility to support financially. GP practices outside of standard contractual arrangements. This regulation still stands and was transferred to the NHS Commissioning Board (NHS England) ‘the Board’ under the Health and Social Care Act 2012 and subsequent amendments. The documents in draft are the outcome of this work.

West Kent PCOG met on the 25th February 2020 and the comments of the group are set out below: PCOG raised a question around Section 4.6 and it’s sub clause proposed and addition “PCCC can apply discretion based on what actions have been taken, when they were done and the outcome achieved or anticipated. Actions already taken should be proactive but need not be exhaustive”.

A key area of concern is the process of what is required for the practice to comply.

It should also be noted by the committee that at the Medway CCG’s PCOG in January 2020 the group made some observations for noting.

The PCOG noted that the policy was quite prescriptive and may limit the discretion of the PCCC to act in certain circumstances. The PCOG supported an approach that balanced flexibility with strong governance, to ensure that applications for support are considered in the context of the needs of individual practices, localities, patients and the CCG’s strategic objectives.

Discretionary Payments: Section 96 Principles and Process


Recommendation: The committee is invited to comment on the Section 96 Discretionary Funding Principles and Process before being passed to the Primary Care Co-Commissioning Committee of the single ICS

For further information or for any enquiries relating to this report please contact: Ruth Wells, Primary Care Development Manager

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There are a number of examples that place stringent requirements on applications before they are considered. For example, Sections 6 and 7 place stringent process requirements on applicants and the CCG. Section 4.6 and its sub-clause also place requirements on practices that may not be reasonable in all circumstances.

Medway CCG therefore proposes an addition of :

PCCC can apply discretion based on what actions have been taken, when they were done and the outcome achieved or anticipated. Actions already taken should be proactive but need not be exhaustive.

This would therefore apply for practices undertaking measures which could take 6 months to come to fruition.





Identified risks & risk management actions: Resource implications: Section 96 funding is not discrete and is found from CCG allocations Legal implications including equality and diversity assessment

N/A


N/A


N/A


N/A

Report history: West Kent PCOG 25 February 2020

Appendices 1. MOU2. Application Form3. S 96 principles and process

Next steps: For PCCC to consider the comments of PCOG, make it’s own comments and pass to the new PCCC for the single ICS

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Memorandum of Understanding (MoU)

For a Section 96 Discretionary Payment

Between

NHS Kent & Medway Clinical Commissioning Group

and

[Practice Name]

Ref: G Date: 03/09/201903/09/2019

Contents Memorandum of Understanding (MoU) ...................................................................... 1

1. PARTIES .................................................................................................... 22. BACKGROUND & PURPOSE .................................................................... 2 3. PRACTICE ROLES AND RESPONSIBILITIESError! Bookmark not defined.4. KEY OBJECTIVES FOR THE MoU ............................................................ 3 5. PRINCIPLES OF COLLABORATION ......................................................... 3 6. GOVERNANCE .......................................................................................... 37. REPORTING .............................................................................................. 38. ESCALATION ............................................................................................ 4 9. CONFIDENTIALITY ................................................................................... 4 10. DURATION ................................................................................................ 4 11. TERMINATION .......................................................................................... 4 12. STATUS ..................................................................................................... 513. SIGNATORIES ........................................................................................... 514. CONTACT POINTS .................................................................................... 5

Appendix 1 - Recovery Plan .................................................................................... 6 1. KEY OJECTIVES ....................................................................................... 6

Appendix 2 – Financial Assistance ......................................................................... 7 1. DESCRIPTION OF FINANCIAL ASSISTANCE ......................................... 7

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1. PARTIES

1) NHS Kent & Medway Clinical Commissioning Group (CCG)

2) Practice Name

2. BACKGROUND & PURPOSE2.1 This MoU forms part of the Section 96 guidance which describes how the CCG is able

to provide financial support to practices that are experiencing significant difficulty in maintaining core services by providing financial assistance.

2.2 This MoU is to be used to provide clarity and understanding of the financial assistance being provided to the Practice by the CCG as set out in Appendix 1 of this MoU (Improvement/Action Plan) and how the CCG is seeking assurance on what can be expected

3. PRACTICE ROLES AND RESPONSIBILITIES3.1 The Practice will fully engage in the Recovery Plan working with the CCG to ensure

the effective use of the resources in a timely and effective manner.

3.2 The Practice acknowledges that a high level of commitment is essential for optimal impact.

3.3 The Practice will adopt an open approach and engage effectively with other stakeholders including other practices, their Primary Care Network (PCN), the Kent Local Medical Committee (LMC) and patients (including the Patient Participation Group (PPG) ) where appropriate to enable an inclusive approach to the Recovery Plan set out in this MOU.

3.4 The Practice will share all information with the CCG as relevant to the delivery of the Recovery Plan of this MOU.

3.5 The Practice retains full responsibility for all aspects of their contractual and professional obligations regarding the provision of primary medical care services to their patients.

3.6 The Recovery Plan must include the Practice maintaining an open list for the purpose of new patient registrations. This must not be restricted by list managing.

3.7 The GP contract held by the Practice must continue to exist for the period of the financial support and beyond the end of the transitional for a minimum of 12 months not including any notice period as dictated by the contract held.

3.8 The Practice must treat any detail of the financial support as commercially sensitive information and specifically will not share or make available to a third party.

3.9 Failure to adhere to the above conditions may result in the CCG requesting partial or full repayment of the financial support provided.

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3.10 The Parties have entered into this MoU in good faith to improve the Practice as set out in this MoU and associated Recovery Plan.

4. KEY OBJECTIVES FOR THE MoU4.1 The Practice shall sign up to the Recovery Plan to achieve the key objectives set out

in Appendix 1 (Recovery Plan).

5. PRINCIPLES OF COLLABORATION5.1 All parties to this MoU will use their reasonable endeavours to co-operate to achieve

the objective of the Recovery Plan in order to effectively address the resilience and sustainability of the Practice, in the overall interests of patients.

5.2 All parties will adhere to the terms set out in this MoU and supporting appendices.

6. GOVERNANCE6.1 The CCG retains the overall responsibility for the use of the Section 96 resources and

has nominated strategic and operational leads who will act as key points of contact for the Practice and the CCG. For the purposes of the Recovery Plan:

a) The Strategic Lead shall be CCG Leadb) The Operational Lead shall be: Practice Lead

6.2 The Strategic Lead will act for the CCG in providing strategic oversight and direction of the Recovery Plan as part of the wider oversight and governance of Section 96 funding in relation to the Practice.

6.3 The Operational Lead will liaise on all operational matters relating to the agreed contributions to support delivery of the Recovery Plan and advise the Strategic Lead, providing assurance that the Key Objectives are being met and that the Recovery Plan is performing within the boundaries agreed with the Practice.

6.4 The Practice shall nominate a Practice Lead and notify the CCG of the name and contact details of the Practice Lead. For the purpose of the Recovery Plan:

a) The Practice Lead shall be:

6.5 The Operational Lead and the Practice Lead shall agree the Recovery Plan and Key Objectives, and will identify the commitments to support its delivery. The Strategic Lead will then approve the Recovery Plan for implementation.

7. REPORTING7.1 The Practice will be required to report on progress of the Recovery Plan.

7.2 Reporting will not be onerous, and will not be the basis of any performance management. Frequency and content of reporting will be as follows:

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a) Submission of a Recovery Plan to effectively address the underlying issuesaround practice sustainability fully detailed with key objectives, actions andmilestones within 6 weeks of signing the MoU.

b) Mid-point review (no later than 3 months from signing the MOU) with exitstrategy to maintain services without ongoing financial support.

c) Evaluation Report against Improvement Plan objectives within one month ofexpiry of this MoU (by 6 months unless an extension is agreed by the CCG )

8. ESCALATION8.1 If either party has any issues, concerns or complaints about the Recovery Plan, or any

matter in this MoU, that party shall notify the other party and the parties shall then seek to resolve the issue by a process of negotiation to decide on the appropriate course of action to take.

8.2 If the issue cannot be resolved within a reasonable time the matter shall be escalated by the Practice Lead and/or the Operational Lead to the Strategic Lead for resolution who may seek advice of the LMC in reaching their decision.

9. CONFIDENTIALITY9.1 The CCG recognises that the success of the Section 96 application relies on the

Practice being open and transparent and may raise the need to address sensitive issues for the Practice. Where this applies, the CCG may enter into a confidentiality agreement to protect certain aspects of the information collected.

10. DURATION10.1 Any financial assistance awarded under section 96 is finite and the Recovery Plan

should describe an agreed exit strategy. Where there is an identified ongoing need, this MoU may be extended at the sole discretion of the CCG to offer an additional period of support to the Practice subject to availability of resources.

10.2 This MoU shall become effective upon signature by both parties, and will remain in effect until xxxx or the date the Recovery Plan is delivered, whichever is the sooner, unless otherwise varied or terminated by the parties.

11. TERMINATION11.1 Either party may terminate this MoU by giving at least one months' notice in writing to

the other party without reason.

11.2 In addition, the CCG may terminate this MoU by giving at least one months’ notice in writing to the Practice where, acting reasonably, and in discussion with the LMC as the representative body, it considers that the Practice has failed to cooperate or to fulfil its roles and responsibilities under this MoU. Please see 3.9

11.3 Where the termination is not a mutual agreement, Parties should refer to Clause 8 (Escalation) of this MoU.

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12. STATUS12.1 This MoU is not intended to be legally binding, and no legal obligations or legal rights

shall arise between the parties from this MoU. The parties enter into the MoU intending to honour all their obligations.

12.2 Nothing in this MoU is intended to, or shall be deemed to, establish any partnership or joint venture between the parties, constitute either party as the agent of the other party, nor authorise either of the parties to make or enter into any commitments for or on behalf of the other party.

13. SIGNATORIES

Signed for and on behalf of NHS Kent & Medway CCG

Insert representatives’ name Insert representatives’ role

_________________________ (Signature)

_________________________ (Date)

Signed for and on behalf of Practice Name

_________________________ (Signature)

_________________________ (Date)

14. CONTACT POINTSStrategic Lead – NHS Kent & Medway CCG Name: Role: Address: Phone number: Email:

Operational Lead – Practice Name: Insert representatives’ name Role: Insert representatives’ role Address: Insert representatives’ address Phone number: Email:

Practice Lead – Name: Role:

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Practice Lead – Address: Phone number: Email:

Appendix 1 - Recovery Plan 1. KEY OJECTIVES1.1 The key objectives for developing greater sustainability and resilience are set out

below.

1.2 These key objectives form the basis of the operational delivery of the Recovery Plan to secure greater sustainability and resilience and present achievable aims for the agreed period of support.

1.3 The objectives should be grouped into three main categories which centre around:

a) securing operational stability;

b) developing more effective ways of working; and

c) working towards future sustainability, including if appropriate helping practices toexplore working collaboratively with the Primary Care Network (PCN) that they area member practice of

1.4 The key ‘SMART’ objectives of this Recovery Plan are: Describe your objectives here under the 3 headings above

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Appendix 2 – Financial Assistance 1. DESCRIPTION OF FINANCIAL ASSISTANCE1.1 This MoU does not act to pass financial assistance to the Practice, but the details of

any financial assistance that has been agreed by the Primary Care Co-Commissioning Committee (PCCC) shall be set out here. .

.

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Reason for Application Brief description of the issue ‐ no more than 500 words

Purpose of Supporti.e. GP locum cover, practice resilience, merger support etc. Pleasenote ‐ if the practice is requesting support for more than one area,a separate application will be required

Period of Support Maximum period of consideration is 6 months

Profile of Costs Overall cost of application

Month 1

Month 2

Month 3

Month 4

Month 5

Month 6

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CQC Rating

% of GP Sessions per week not routinely filled

18/19 QoF Achievement ‐ Clinical Maximum 435

18/19 QoF Achievement ‐ Public Health Maximum 124

Does the practice have a closed or managed list, or does not routinely accept new registrations?

GP Survey ‐ Would you recommend your GP Surgery to someone who has just moved into the area? (% No)

Data from the latest survey

GP Survey ‐ Ease of getting through on the telephone (% not at all easy)

Data from the latest survey

How many GP Partners have left the practice in the last 2 years?

How many GP Partners have joined the practice in the last 2 years?

Have any of the GP Partners or Salaried GP's taken 24 hour retirement?

Are any of the GP Partners or Salaried GP's planning to retire in the next three years?

Number of GP Partner Vacancies (and w.t.e.)

Number of GP Salaried Vacancies (and w.t.e.)

Number of Clinical Vacancies (excluding GP's and w.t.e.)

Please include clinicians roles

Number of Administrative Vacancies (and w.t.e.)Please include administrative roles

Significant Practice Changes

Please include any significant issues that have not been

captured anywhere else on this form

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Income and Expenditure Summary

INCOME 17/18 18/1919/20

EstimateEXPENDITURE 17/18 18/19

19/20 Estimate

Global Sum Drugs and instrumentsNetwork Participation Instrument repairs and consumablesOut of hours service NHS leviesCorrection factor Travelling expensesSeniority allowance RentRoom and reception service Rates and waterFY2 clinical supervisor Heat and lightPhysician Associate supervisor InsuranceFinal year student supervisor Gardening expensesSalary support Laundry and cleaning8‐8 Reimbursed staff salary Clinical waste disposalCCG prescribing incentive scheme Trade refuseStudent nurse training Training expensesQuickstart productive GP backfill funding Staff welfareHERE Workflow training backfill funding Pension contributionsStudent nurse placement Locums and professional assistanceMedical records movement Nurses and health careChildhood immunisations ‐ 2yr Scan and collateChildhood immunisations ‐ 5yr Advance Nurse PractitionersInfluenza immunisations Paramedic PractitionersPneumococcal TelephoneMinor surgery Printing, postage and stationeryLearning disability AdvertisingRotavirus Licences and insuranceShingles Locum insuranceMeningitis Repairs and renewalsMMR Private healthcareChildhood vaccinations Medical defence feesEnhanced frailty scheme SubscriptionsQrisk Indemity insuranceE‐Referrals CQC feesDMARDS SundriesPertussis Equipment hirePhlebotomy AccountancySmoking cessation Payroll bureauNHS Health Checks Computer costsLeg ulcers ConsultancyHPV vaccine Legal fees

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Treatment room Bank chargesDiabetes Credit cardOGTT Late payment fees24hr BP monitoring Depn of fixtures and fittingsCommunity based ECG Depn of computer equipmentEnd of life HMRC SettlementQoF Aspiration CaretakerQoF Achievement Staff salariesRent Pension contributionsRates and water National Insurance contributionsClinical waste disposal Partner monthly drawingsDrugs Parter annual dividend or paymentIndemnity insurance Other practice expenses (please list)CQC feesPhone contract termination feeMedical reports/Crem/TWIMC/FormsSundryVaccinationsAny refunds the practice has receivedOther practice income (please list)

Total Income Total Expenditure

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Which PCN does the practice belong to?

Has the practice explored collaborative working with collegues in their Primary Care

Network (PCN)?

If yes, please describe what opportunities have been explored and the rationale for not progressing withany identified opportunities

Has the practice considered closing their list?Would the closure of the practice list bring any tangible benefits and alleviate the current issues?

Has the practice considered amending their boundary?

Would the amendment of the practice boundary bring any tangible benefits and alleviae the current issues?

Has the practice considered closing a branch surgery (if applicable)?

Would the closure of a branch surgery bring any tangible benefits and alleviate the current issues?

What steps have the practice considered to alleviate the current issues?

Please list all steps considered Timescale for delivery Cost of delivery

Consideration No 1

Consideration No 2

Consideration No 3

Consideration No 4

Consideration No 5

Consideration No 6

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Notes for Completion1. Practice to complete all the yellow boxes ‐ please add on further rows if required2. All staff to be included in the head count ‐ clinical and non‐clinical3. Complete the staff count as 1 April 2019 ‐ any changes to the staff complement should be tracked in columns I, J and K4. Any additional information regarding the staff member to be added to the notes column

NAME START DATE WTE SESSIONSSALARY PER MONTH

LOCUM COST PER SESSION

CLINICAL / ADMIN

POSITIONDATE OF LEAVING

REPLACED YES / NO

REPLACED BY NOTES

PRACTICE NAME CLINICAL AND NON‐CLINICAL STAFF ‐ 1 April 2019

GROSS SALARIES INCLUDING ER'S AND EE'S PENSION CONTRIBUTIONS

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Item Answer

1Have all parts of the application form been completed?

2Have all accompanying documents been completed?

3Has any supporting evidence been attached to the application?

4Has the Practice Health Check document been completed and attached?

5Has the declaration been signed by the Senior Partner?

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Declaration

That the information contained in this application is factual and accurateThat the practice is aware the CCG will measure and monitor the affectiveness of any

financial assistance awardThat if any of the circumstances change the basis on which the financial assistance was

given then the money may be clawed back or terminated

Senior Partner

Name

Signature

Date

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Author: Cheryl Turner Approved by:

Date: 8 January 2020 Version:1.1

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Document Version Control

Document Title Discretionary Payments: Section 96 Principles and Process

Version Version 1.1

Author Cheryl Turner

Date 3 September 2019

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Contents


1. BACKGROUND .......................................................................................... 4 2. LOCAL CONTEXT ..................................................................................... 4 3. INTRODUCTION & PURPOSE .................................................................. 4 4. KEY PRINCIPLES ...................................................................................... 5

5. CONSIDERATIONS ................................................................................... 6 6. CRITERIA .................................................................................................. 7 7. PROCESS .................................................................................................. 7 8. REPORTING ............................................................................................ 11 9. MAINTAINING RECORDS ....................................................................... 11 10. REFERENCES ......................................................................................... 12

Appendix 1 - Application template

Appendix 2 - GP Comparison and Plan

Appendix 3 - Memorandum of Understanding template

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1. Background

1.1 Section 96 payments (sometimes referred to as discretionary payments or funding locally) are a legacy from the NHS Act 2006, which provided Primary Care Trusts (PCTs) with the facility to support financially. GP practices outside of standard contractual arrangements. This regulation still stands and was transferred to the NHS Commissioning Board (NHS England) ‘the Board’ under the Health and Social Care Act 2012 and subsequent amendments.

1.2 This statutory provision is designed to offer short term and immediate support to providers of primary medical services to secure practice improvement and build longer term resilience rather than a short term quick fix. All other routes of support should be explored prior to considering use of section 96.

1.3 The provision is not designed to offer long term financial assistance to providers of primary medical services. In the first instance the CCG would seek to support practices through the GP Resilience Programme (GPRP) working with NHS England (NHSE).

2. Local Context – Kent & Medway

2.1 Primary Care is facing unprecedented demands. Nationally, an aging population, increasing workload and challenges with the recruitment and retention of GPs pose significant challenges to the continued delivery of high quality primary care services.

2.2 Locally GP practices are not immune to these challenges. In recent months an increasing number of providers are sharing their challenges with the CCG and asking for support in addressing them. In many of these cases the continued provision of primary care services has been put at risk as a result of uncertain business continuity.

3. Introduction and Purpose

3.1 Section 96 of the NHS Act (2006) (as amended) makes provisions for commissioners to provide assistance and support to primary medical services contractors, including financial support: Assistance and support: primary medical services

(1) The Board may provide assistance or support to any person providing orproposing to provide–

- primary medical services pursuant to section 83(2),

- primary medical services under a general medical services

contract, or

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- primary medical services in accordance with section 92

arrangements.

(2) Assistance or support provided by the Board under subsection (1) isprovided on such terms, including terms as to payment, as the Boardconsiders appropriate.

(3) “Assistance” includes financial assistance.

3.2 Section 96 states that the Clinical Commissioning Groups (CCGs) under delegated authority may provide financial assistance, on terms as it considers appropriate.

3.3 The CCG as the commissioner has discretion as to the type and level of financial assistance and the payment mechanism that it may choose to employ

3.4 The CCG is expected to demonstrate publicly what it is spending its money on, what it is getting for its money and of that funding that is allocated to support initiatives that this is done fairly and in the best interests of the organisation and public funds.

3.5 When providing any financial assistance the CCG must be able to demonstrate that we have acted with propriety, that we have understood any wider financial requirements as set out in the latest NHS England Standing Financial Instructions (SFIs), that we have followed all steps to provide best value for money and that we have followed requirements in relation to public sector bodies as stipulated in Managing Public Money (January 2015), available at: https://www.gov.uk/government/publications/managing-public-money

4. Key Principles

4.1 Section 96 exceptional discretionary funding is intended to be used to safeguard patients’ interests by providing additional funding to support practices facing a crisis situation.

4.2 All financial assistance must be provided within the principles of openness, fairness, probity and accountability.

4.3 It must be demonstrated how the financial assistance supports the functions of the CCG and its strategic objectives as well as any policy objectives

4.4 Financial assistance must demonstrate value for money and be in the best interests of the CCG and the patients.

4.5 Financial assistance must be proportionate to the identified need and represent better value for the taxpayer than alternative solutions

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https://www.gov.uk/government/publications/managing-public-money



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4.6 Prior to considering the issuing of assistance and support under Section 96 GP practices should demonstrate to the CCG that they have exhausted alternative solutions to the challenges they are facing.

4.6.1 This includes GP practices exploring opportunities if relevant to work

together with others to develop shared back‐office services and to find collective ways of delivering primary care at scale, such as within a PCN (Primary Care Network).

4.7 Any funding awarded should take note of the General Medical Services Statement

of Financial Entitlements (SFE) and that funding related to premises is not subject to the Premises Cost Directions.

4.8 Funding must not contradict the intent of the General Practice Forward View

(GPFV) which requires equity of global sum for the delivery of General Medical Services (GMS).

4.9 Financial assistance will only be made available in exceptional circumstances.

4.10 Financial assistance will only be provided for the incremental cost of a locum i.e. the total cost of a locum less the South East GP average cost

4.10.1 Evidence of locum invoices and advertising costs will be requested to support application for financial assistance

4.11 Financial assistance will be for a set period only 4.12 The certified accounts for the previous financial year, and the management

accounts for the current financial year, cash flow and declared earnings, will be required. Failure to provide this information will result in the application not being considered.

4.13 Application form (Appendix 1)

Memorandum of Understanding (Appendix 2) GP Plan and Comparison (Appendix 3)

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5. Considerations

5.1 The NHS Act does not specifically define circumstances would warrant CCG assistance, other that stating that the CCG should believe it to be appropriate.

5.2 A general principle guiding the use of this statutory provision is that funding should only be provided when all other routes of financial assistance have been explored. It should also be the opinion of the CCG that without this assistance the risk of a provider being unable to continue to deliver primary medical services is unacceptably high.

5.3 Individual decisions to agree assistance for providers of primary medical care services do not set a precedent for the future.

5.4 GP practices should demonstrate that they have reviewed the appropriate tools (i.e. 10 High Impact Actions) GP practices should complete the Health Check Tool, which might provide indications of areas for change and/or improvements: https://www.england.nhs.uk/south/publications/sustainable‐gp/

6. Criteria

6.1 In order to assess eligibility for financial assistance the following criteria will be reviewed. The criteria are listed in order of importance.

No Criteria Rationale

1 There must be evidenced extenuating circumstances within the practice population related to:

a. Workloadb. Patient demographics

that impact practice business and patient services

This evidence may include an IMD score of 35 or higher for the practice population or evidence that local demographics dictate workload is not adequately reflected in the Carr-Hill funding formula. This is proven by evidence of the downward weighting applied through the funding formula

Evidence of the consequential impact on a practice workload must be provided

2 No doctor in the practice should have declared pensionable earnings in excess of £112,000 p.a. for Partners, and (apportioned as relevant for part time GPs)

Support not designed to increase pensionable income of GPs

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https://www.england.nhs.uk/south/publications/sustainable‐gp/



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3 Practice expenses must be evidenced to be greater than 63%

National average ratio of expenses: profit is 63:37

7. Process

Stage

Action

1

Practice raises its sustainability issue with the CCG. Verify contract payments are correct.

Practice & Primary Care Team (CCG)

2

Practice submits Section 96 application accompanied with level of support requested, for what period, and for type of expenditure with evidence provided to support application

Practice

3

Primary Care team review submission and if necessary request for further information / supporting documentation

Primary Care Team (CCG)

4

Review and validation of practice information. Ensuring that: - The practice need is confirmed;- The practice agrees to receiving the

support and any conditions placed onthe support;

- The support is non recurrent i.e. practicehas provided details of its plan torecover the position and demonstratethat the short term support will deliver asustainable solution in the long term.

- Performance Managementarrangements in respect of the financialassistance

- The case represents value for money;- Financial assistance is a better option

than any alternatives

Primary Care Team (CCG)

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Stage

Action

5

Review of financial evidence including certified accounts for the previous year and management accounts for the current year, cash flow, declared earnings etc. Consideration whether the financial assistance will be sufficient to achieve the objectives. Consideration of value for money vs alternatives Total likely overall financial risk to the CCG

Finance (CCG)

6

All Financial Assistance provided must be in compliance with NHS England SFIs. As such any Application for financial assistance must have the authorisations set out below.

Finance (CCG)

7

Requests for assistance should be considered taking into account the impact if support is not provided and the provider is unable to continue to deliver the service.

Primary Care Team

8

Application from the Provider along with SBAR (Situation Background Assessment Report) containing operational and financial reviews set out. Presented to the Primary Care Co-Commissioning Group (PCCOG) for consideration with a recommendation to the Primary Care Co-Commissioning Committee (PCCC) for decision

PCCOG

9

Application from the Provider along with SBAR (Situation Background Assessment Report) containing operational and financial reviews set out. Presented for authorisation at the Primary Care Co-Commissioning Committee (PCCC) >£50,000 with a recommendation from PCCOG for

PCCC

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Stage

Action

consideration and decision

10 Practice advised of outcome Primary Care Team

11 MOU (Memorandum of understanding) populated and signed by practice, and CCG

Practice, Primary Care Team

12 Payment set-up on a non-recurrent basis Finance

13 Review of MOU objectives mid-way through period of support

Practice, Primary Care Team

14 Routine reporting via the Primary Care Activity Report (PCAR) Primary Care Team

15

Advise practice of continuation or further review of support depending on MOU progress

Primary Care Team

16 Final Review and reporting to PCCC (if required) Primary Care Team

7.1 The GP Practice Application for Discretionary Funding Support must be completed

setting out the financial assistance required. This must include:

The level of financial assistance How the financial assistance will be divided How the financial assistance will be paid out Justification as to why the financial assistance is value for money

7.2 The application must be endorsed by:

Primary Care Finance for availability of funding Primary Care Co-Commissioning Committee

7.3 Once financial assistance has been agreed the following template will require to be

completed.

1. Name and reference code of practice for whom discretionary payment request is

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being made 2. Is practice already identified under any

national or local programme providingsupport? If so, please provide the name ofthat programme.

(bullet point summary if practice known to be in difficulty and any support provided previously or current)

3. What has precipitated the request for urgentdiscretionary funding?

(bullet point summary of issues to be provided)

4. What practical and financial support has thepractice already invested to resolve theseissues? (bullet point summary of support invested in)

5. What help and support is being requested –bullet point descriptions and cost of eachform of support

6. How long is the financial assistanceanticipated to be needed (either to achievea resolution or to prepare a business casefor longer term support)

7. Confirmation that this request for urgentfunding is likely to represent better value formoney than contract hand-back/the needfor step in arrangements

8. Prepared by:

9. Authorised for payment by:

Director for Primary Care <£50,000

Primary Care Co-Commissioning Committee and/or not agreed by the Primary Care Co-Commissioning Operational Group >£50,000

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10. Reported to /involvement of CCG?

7.4 NHS England and CCGs under delegated authority may only enter into contracts within the statutory powers delegated to it by the Secretary of State for Health and must comply with the following:

NHS England Scheme of Delegation and Standing Financial Instructions; EU Directives and other statutory provisions

8. Reporting

8.1 The primary care commissioning activity report (PCAR) was introduced in 2016/17 as a new bi-annual collection to support greater assurance and oversight of NHS England’s primary care commissioning responsibilities. It seeks to replace what have often been variable and ad hoc requests for information with a more systematic approach.

8.2 The report is managed through UNIFY2 and focuses on key operational areas for commissioned general practice services. It collects information on local commissioning activity regardless of the commissioning route including Financial assistance to providers covered under the section of PCAR ‘Equitable funding’‘

9. Maintaining Records

9.1 A clear audit trail of all financial assistance authorised, along with any expenditure incurred under this arrangement, must be maintained and reported by the CCG. Summary information will be collected biannually via PCAR but you should also maintain adequate records such that you are able to respond to any other routine financial reporting arrangements.

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10. References

NHS England Primary Medical Care Policy and Guidance Manual (PGM) (Version 2) April 2019

DGS and Swale discretionary payments policy March 2019

EK 2019.01 Discretionary Payments S96 process

WK Discretionary Payments S96 guidance

Medway S96 application DRAFT

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Date: 24/03/2020 Reporting Officer: Ruth Wells Agenda Item: 13 Lead Director: Gail Arnold Version: 1.0 Report Summary:

This report provides an update to the West Kent Primary Care Co-commissioning Committee on the progress towards agreeing the terms of reference for the Kent and Medway Primary Care Co-commissioning Operational Groups that will come into operation with effect from 1 April 2020.

West Kent PCOG met on 25 February 2020 and made the following comments:

The group recognised there were some significant differences the key points being; • PCOG to become a strategic forum.• Membership now includes CCG independent member, up to 2 clinical leads, CCG director,

Senior Commissioning Manager, Senior Local Care Commissioning Manager or deputy• Quorate states 6 or 7 members to be present

The LMC recognised and welcomed the inclusion of GP representation within the groups.

There was concern about the increased quoracy when serving a monthly PCCC which could potentially increase the meeting schedule for PCOG along with increased membership.

There was also concern about the impact on the CCG Director with responsibility for Primary care or their nominated deputy for the purposes of this group when there will be 5 PCOGs vis a vis the scheduling of meetings around one PCCC date which could raise problems with attendance and deputising.

Finally a query was raised in respect of item 12.4 Conflict of interest in terms of a GP representative not being part of a provider company or being a director of a GP federation or clinical director of a PCN – it was felt this may limit GP availability.

Kent and Medway Primary Care Operational Group Terms of Reference


Recommendation: The committee is invited to comment on these PCOG Terms of Reference before being passed to the Primary Care Co-Commissioning Committee of the single ICS

For further information or for any enquiries relating to this report please contact: Ruth Wells, Head of Development and Delivery

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Risk to obtaining required levels of membership. Mitigating factors include GB members now available

Resource implications: Potential impact on CCG Director with Portfolio for Primary Care Move to monthly PCOG increases resource demand


N/A


N/A


Referred to in Item 1.24


N/A

Report history: PCOG 25/2/2020

Appendices Appendix 1 Kent and Medway Draft TORS

Next steps: For PCCC to comment and pass to the new PCCC for the single ICS

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Page 1 of 8 Version 5 (4th Feb 2020)

Kent and Medway Clinical Commissioning Group Primary Care Co-commissioning Operational Group(s)

Draft Terms of Reference

1 Introduction

1.1 Kent and Medway Clinical Commissioning Group (CCG) has established the Kent and Medway CCG Primary Care Commissioning Committee (PCCC). The PCCC functions as a corporate decision- making body for delivering the delegated agreement and the exercise of the delegated functions from NHS England.

1.2 The PCCC has directed that one or more Primary Care Co-commissioning Operational Groups (PCCOGs) are established to provide operational management level co-ordination, assurance and support to the Committee in order to meet the requirements of the delegation agreement and delivery of the Primary Care strategy.

1.3 PCCOGs will be established for the following geographical areas:

Ashford and Canterbury & Coastal Dartford, Gravesham and Swanley Medway and Swale South Kent Coast and Thanet West Kent

1.4 The PCCOGs will consider local commissioning needs as part of their deliberations and work. This will ensure that Integrated Care Partnerships (ICPs) and Primary Care Networks (PCNs) are able to co-ordinate through general practices, community services and hospitals to meet the needs of local people requiring care.

2 Statutory Framework

2.1 NHS England has delegated to the CCG the authority to exercise the primary care commissioning functions as set out in the PCCC Terms of Reference (Annex A).

2.2 These Terms of Reference should be read in conjunction with the PCCC Terms of Reference

3 Role of the PCCOG

3.1 The PCCOG is established as a sub-committee of the Kent and Medway PCCC. Its role is to develop commissioning plans and commissioning opportunities for the development and delivery of high quality local primary care medical services.

3.2 The PCCOG has no delegated decision making authority but may make recommendations to the PCCC and officers of the PCCC who have delegated authority, in accordance with CCG Standing Orders, Scheme of Reservation and Delegation and any Scheme of Delegated Financial Limits.

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3.3 The PCCOG will oversee and co-ordinate the operational delegated arrangements, supporting the delivery of the delegated responsibilities relating to the commissioning of primary medical services under section 83 of the NHS Act 2006.

3.4 In undertaking its role, the PCCOG will:

Provide a strategic forum to develop commissioning plans and commissioningopportunities for the development and delivery of high quality local primary caremedical services

Oversee and co-ordinate the delegated arrangements, ensuring delivery of thedelegated functions in line with the statutory framework

Manage the day to day business associated with the commissioning andcontracting of primary care in line with the statutory framework

Provide assurance to the PCCC that there are robust systems and processes inplace for monitoring, managing and assuring the quality, safety and sustainabilityof primary care medical services and for driving continuous service improvementincluding the development of Primary Care Medical Services. This will be inliaison with the Quality and Safety Committee as appropriate

Provide specialist knowledge and advice in relation to all aspects of primary caremedical services including commissioning, contracting, performance managementand quality assurance

Oversee locally commissioned services for wider primary care

Oversee the delivery all Direct Enhanced Services including the Network contactDES and the introduction of the seven service specifications

3.5 PCCOG will make recommendations on proposals, developments and investments to the PCCC.

3.6 PCCOG will provide sufficiently detailed reports to the PCCC to either provide assurance or enable recommendations to be made. Where recommendations have been made, a record of these and the rationale shall be reported.

3.7 PCCOG has no delegated authority. It will develop business cases and options appraisals to enable recommendations to be presented to the PCCC for review and decision making in relation to the following:

3.7.1 Delivery of GMS, PMS and APMS contracts (including Direct Enhanced Services (DES)

3.7.2 Establishment of new GP practices (including branch surgeries)

3.7.3 Practice mergers and practice closures

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3.7.4 Practice boundaries changes

3.7.5 Poorly performing GP Practices, including responding to CQC inspections and NHS England

3.7.6 GP Information Technology requirements and future planning

3.7.7 GP Resilience plans and practice business continuity arrangements

3.7.8 GP workforce plans

3.7.9 Premises and strategic estates planning functions in line with the Premises Cost Directions

3.7.10 Applications for discretionary payment

3.7.11 Commissioning of urgent primary care for out of area patients

3.7.12 Locally Commissioned Services and Local Incentive Schemes

3.7.13 Reinvestment of PMS premium funding released as a consequence of the PMS review process

3.7.14 Reviewing data and information in relation to the quality of Primary Care with a view to reporting exceptions to the Quality and Safety Committee

3.7.15 Ensure meaningful engagement of patients and the public in decision making;

3.7.16 Developing general practice to ensure continuous quality improvement

3.7.17 Primary Care Medical Services procurement opportunities

4 Scope of Authority and Decision-Making

4.1 PCCOG will make recommendations on proposals, developments and investments to the PCCC. This will be in line with any standard operating procedures, policies or processes as determined by the PCCC.

5 Membership

5.1 The PCCOG shall consist of the following members:

A CCG Independent or Associate Independent member Up to two GPs who may be a clinical lead for primary care The CCG Director with responsibility for Primary Care or their nominated deputy

for the purposes of this group The CCG Chief Finance Officer or their nominated deputy for the purposes of this

group A CCG senior primary care commissioning manager or their nominated deputy

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A CCG senior local care commissioning manager or their nominated deputy

5.2 The PCCOG will also invite or allow the following attendees who may contribute to discussions, but are not allowed to participate in any decision making regarding proposals and recommendations :

A Kent LMC representative A Practice Manager representative A senior primary care estates manager or their nominated deputy A CCG senior quality manager (with a primary care remit) or their nominated

deputy NHS England and NHS Improvement – South East Region representative

5.3 The PCCOG may call additional individuals to attend meetings on a case by case basis to inform discussion. The Committee may also invite or allow additional individuals to attend meetings on a more regular basis. Attendees may present at meetings and contribute to discussions, but are not allowed to participate in any vote.

5.4 Officers and GP members of the PCCOG may nominate deputies to represent them in their absence and agree proposals and recommendations as if they were a Member of the meeting.

5.5 Other attendees may nominate deputies to attend in their absence.

6 Meetings and Voting

6.1 Meetings of the PCCOG will not be open to the public

6.2 The PCCOG will operate in accordance with the CCG’s Standing Orders. The secretary to the Group will be responsible for giving notice of the meetings. This will be accompanied by an agenda and supporting papers and sent to each member representative no later than five working days before the date of the meeting. When the PCCOG Chair deems it necessary in light of the urgent circumstances to call a meeting at short notice, the notice period shall be such as they shall specify.

6.3 The aim of PCCOG will be to achieve consensus wherever possible with the show of hands when making a recommendation to PCCC. Each voting member of the Group shall have one vote. The Group shall reach decisions by a simple majority of members present, subject always to the meeting being quorate. In cases where all efforts have been explored and a simple majority cannot be reached, the Chair shall have a second and deciding vote, where the vote is tied.

6.4 If an urgent matter is needed to be considered prior to the next scheduled meeting and or it is not considered possible to call a full meeting, the Group Chair may decide to convene a virtual meeting. The arrangements for such meeting will be determined by

the Chair in discussion with the Executive Director with responsibility for Primary Care or their nominated deputy . In all other respects the meeting will be managed in

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accordance with these Terms of Reference, as if it were a planned meeting, including the minute taking and decision making. Any decision made virtually will be noted at the next available and appropriate meeting of the Group.

7 Quorum

7.1 A quorum shall be six/seven voting members, one of whom shall be an independent/independent associate member, one shall be a CCG officer with primary care commissioning knowledge and one shall be a clinician. With the exception of independent/associate independent members, deputies may attend in place of the regular members and vote on their behalf where applicable.

7.2 Members who are not physically present at a meeting but are present through the means of teleconference or other acceptable digital media shall be deemed to be present and count towards the quorum as appropriate.

7.3 If any representative is conflicted on a particular item of business they will not count towards the quorum for that item of business. If this renders a meeting or part of a meeting non quorate, a non-conflicted person may be temporarily appointed or co-opted to satisfy the quorum requirements, subject to the agreement of the Chair.

7.4 If a Committee meeting is not quorate the Chair may permit the appointment or co-option of additional members if necessary, subject always to there not being a GP voting majority.

7.5 In circumstances where all clinicians are conflicted and it is not possible to co-opt or appoint a non-conflicted clinician to satisfy the quorum requirements, the Chair may suspend the requirement for a clinician to be part of the quorum and deem the meeting quorate upon all other voting members on the Committee being present. Unless the matter to be discussed is of such confidential or sensitive nature that it would require the exclusion of GP attendance, where possible, a GP or a representative of the LMC should always be in attendance at a meeting to contribute to discussion and or observe as appropriate, even if they are not able to vote.

7.6 Members of the Group have a collective responsibility for the operation of the Committee. They will participate in discussion, review evidence and provide objective expert input to the best of their knowledge and ability, and endeavour to reach a collective view

8 Frequency and Notice of Meetings

8.1 The Group shall meet bi monthly unless circumstances necessitate the need to meet more frequently as agreed by the Committee.

8.2 Notice of any Group meeting must indicate:

8.2.1 Its proposed date and time, which must be at least ten (10) business days after the date of the notice, except where a meeting to discuss an urgent

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issue is required (in which case as much notice as reasonably practicable in the circumstances should be given)where it is to take place

8.2.2 an agenda of the items to be discussed at the meeting and any supporting papers

8.2.3 if it is anticipated that members of the Group participating in the meeting will not be in the same place, how it is proposed that they should communicate with each other during the meeting

8.3 Notice of a Group meeting must be given to each member of Group in writing.

8.4 Failure to effectively serve notice on all members of the Group does not affect the validity of the meeting, or of any business conducted at it.

9 Secretary

9.1 The Company Secretary shall ensure provision of business support services to the

Committee in discussion with the Executive Director with responsibility for Primary Care or their nominated deputy. The duties of the support service in this regard include but are not limited to:

9.1.1 Agreement of the agenda with the Chair of the Committee and the

Executive Director with responsibility for Primary Care of their nominated deputy

9.1.2 Arranging the venue and other house-keeping requirements

9.1.3 Taking the minutes and keeping a record of matters arising and issues to be carried forward

10 Agendas and Circulation of Papers

10.1 Before each PCCOG meeting an agenda and papers will be sent to all members and regular attendees no less than five (5) business days in advance of the meeting.

10.2 If a PCCOG member wishes to include an item on the agenda they must notify the Chair or Chief Operating Officer or their nominated deputy, no later than ten (10) business days prior to the meeting. In exceptional circumstances for urgent items this will be reduced to five (5) business days prior to the meeting. The decision as to whether to include the agenda item is at the discretion of the Chair.

11 Minutes and Reporting

11.1 Minutes of the PCCOG shall be prepared by the secretary and submitted for agreement at the following PCCOG meeting.

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11.2 A copy of the minutes and or a summary of PCCOG meetings will be presented to the PCCC as required.

12 Conflicts of Interest

12.1 Conflicts of Interest shall be dealt with in accordance with the NHS England statutory

guidance and relevant CCG policies. It is important that conflicts of interests are managed appropriately within subcommittees and sub-groups. As an additional safeguard, it is recommended that sub-groups submit their minutes to the primary care commissioning committee, detailing any conflicts and how they have been managed. The primary care commissioning committee should be satisfied that conflicts of interest have been managed appropriately in its sub-committees and take action where there are concerns

12.2 The PCCOG shall have a Register of Business Interests that will be presented as a standing item on the meeting agenda.

12.3 All Members and attendees who are invited to take part in any discussion (voting and non-voting) are required to declare any interest relating to any matter to be considered at each meeting, in accordance with the CCG’s constitution and the CCG Standards for Business Conduct and Managing Conflicts of Interest Policy. At the sole discretion of the Chair, individuals who have declared an interest may be allowed to participate in the discussion, but will not participate in any vote and may be requested to leave the meeting for any or the entire item in question.

12.4 To avoid a potential conflict of interest any GP representative on the PCCOG will not be a Director of a provider company (except where that company holds a primary medical services contract) or a Director of a GP Federation or Clinical Director of a Primary Care Network. Members of Primary Care Networks/GP Federations/GP Provider companies will be permitted to attend providing they can confirm they are not on the Board of Directors and declarations of interest are made clear. This is in line with paragraph 79 of the Managing Conflict of Interest: Revised Statutory Guidance for CCGs 2017i.

13 Working Groups

13.1 PCCOG may appoint tasks to such working groups or individual members as it shall see fit, provided that any such appointment is consistent with NHS England regulations and the CCG’s Constitution and associated documents and policies, including but not limited to Standing Orders, the Overarching Scheme of Reservation and Delegation and the PCCC Terms of Reference. Any such appointment shall be appropriately recorded.

14 Confidentiality

14.1 Members of the PCCOG shall respect the confidentiality requirements set out in as set out in the CCG’s Standing Orders, relevant Corporate Policies and these Terms of

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Reference unless separate confidentiality requirements are set out for the Committee in which event these shall be observed.

15 Standards of Business Conduct

14.1 PCCOG members, members and/or invited observers must maintain the highest standards of personal conduct and in this regard must comply with:

14.1.1 The laws of England and Wales;

14.1.2 The NHS Constitution;

14.1.3 The Nolan Principles;

14.1.4 The standards of behaviour set out in the CCG’s Constitution and supporting documents and policies, as they would be reasonably expected to know;

14.1.5 Any additional regulations or codes of practice relevant to the Committee.

16 Review of Terms of Reference

16.1 These Terms of Reference and the effectiveness of the PCCOG will be reviewed at least annually. The PCCOG will recommend any proposed changes to the terms of reference to the PCCC for approval in accordance with the CCG Constitution.

__________________________________________

Approved: April 2020

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NHS West Kent CCG

2017-19 Local Incentive Scheme review and outcomes.

Date: 24th March 2020Reporting Officer: Priscilla Kankam Agenda Item: 14 Lead Director: Gail Arnold Version: 1.0 Report Summary:

The paper gives an update on the Local Improvement Scheme 2017-19 (Final Report) to the Primary Care Co-Commissioning Committee.

5.1 Feedback from practices indicates a good level of engagement with the 2017-19 scheme. Practices are progressing with the requirements set out in the scheme.

5.2 From the national published figures, it can be broadly concluded that the LIS scheme has had positive impact on patient care, overall outcomes and experience. Even though, engagement in this year’s scheme has been poor compared to previous years, most practices found it a worthwhile exercise and an important area of focus. Particularly, the opportunity to identify a cancer lead and share good practice in house was a positively received and delivered.


Strategic objectives links: All


All


None

Resource implications: None

This paper is for: For information

Recommendation: The Primary Care Commissioning Committee is asked to note the update on the Local Improvement Scheme 2017-19 final Report

For further information or for any enquiries relating to this report please contact;

Priscilla Kankam, Head of Primary Care and medicines optimisation

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NHS West Kent CCG

Legal implications Not applicable

Equality & Diversity Assessment

Has an equality analysis been undertaken? ☐Yes☒Not applicable

Report history: N/A

Appendices 1 – LIS 2017-19 2 – Evaluation Proposal – LIS 2017 – 19 3 – LIS 2017-19 Interim Report

Next steps: See summary

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Patient focused Providing quality, improving outcomes

Local Improvement Scheme 2017-19 Final Report

DATE March 2020

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Purpose

1.1 The purpose of the report is to provide a final update on the 2017-19 Local Improvement Scheme (LIS) offered to member practices to the CCG Primary Care Co-Commissioning Committee (PCCC).

2 Introduction and background

2.1 The 2017-19 LIS (Appendix 1) was ratified on the 5th of September 2017 following a proposal from NHS West Kent CCG primary care team. Recommendations for the scheme were based on the outputs of a task and finish group and feedback received from colleagues in primary care. The scheme was launched to practices in October 2017.

2.2 The strategic intent of the Local Improvement Scheme 2017-19 was to support the delivery of NHS West Kent Clinical Commissioning Group’s (NHS WKCCG) objectives not delivered under the General Medical Services (GMS) and Personal Medical Services (PMS) contracts or other National and Local schemes available to general practice. Historically, Local Improvement Schemes (LIS) have been utilised within West Kent as a mechanism to reward quality improvements for a range of areas within primary care.

2.3 A small task and finish group was set up to develop the LIS. The group worked through a number of suggestion made by primary care clinicians on possible areas to improve patient care, outcomes, experience and costs to the CCG. The suggestions were mapped against tools utilised by CCG commissioners to identify areas of opportunity to improve patient outcomes and reduce spend such as the Right Care data packs and Cancer Data Dash Board.

2.4 The Right Care packs (previously known as Commissioning for Value Packs) provides the commissioning system with data, evidence, tools and practical support around spend, outcomes and quality, the programme can help clinicians and commissioners transform the way care is delivered for their patients and populations and reduce variation in health inequalities. The Right Care pack compares our CCG to the 10 most demographically similar CCGs.

2.5 The group focussed on two key areas.

• Improvement in cancer care: Cancer is a major cause of death, accounting for around aquarter of deaths in England. More than 1 in 3 people will develop cancer at some point intheir life. In January 2011 the Government published Improving Outcomes - a Strategy forCancer. This document sets out how the Government plans to improve cancer outcomes,including improving survival rates through tackling late diagnosis of cancer. Screening is away of testing healthy people to see if they show any early signs of cancer. Bowel cancerscreening can save lives. Screening aims to detect bowel cancer at an early stage, whentreatment has the best chance of working. The test can also find polyps (non-cancerousgrowths), which might develop into cancer. Polyps can easily be removed, to lower the riskof bowel cancer. In England, Wales and Northern Ireland people over the age of 60 areinvited to take part in bowel cancer screening, whereas in Scotland, screening starts fromage 50. Screening is every two years until the age of 75.

• Management of obesity: The key aim of this element of the scheme is to provide anopportunity for practices to focus on identifying patients who are obese and offer targetedinterventions when appropriate. This also creates the opportunity for practices to capturepatients at risk of other long term conditions such as hypertension and diabetes. In

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England, most people are overweight or obese. This includes 61.9% of adults and 28% of children aged between 2 and 15. People who are overweight have a higher risk of getting type 2 diabetes, heart disease and certain cancers. The Commissioning for Value Pack for West Kent CCG published in December 2016 indicated that 63.4% of the population in West Kent are obese compared to and England Average of 64.6%.

2.6 The scheme comprised of two Quality Improvement (QI) initiatives focussing on the 2 areas identified with a delivery component in each of the two years 2017/18 and 2018/19. The weighting of funding across the two years was spread over 2years; £0.60 in year one and £0.90 in year two, reflecting the effort required in each year but seeking to maintain a financial flow to practices in each year. Details of the scheme in appendix 1.

2.7 None of the elements included in the LIS 2017-19 duplicated elements in other local schemes or national initiatives that could attract a double payment.

2.8 In November 2017, the committee considered and approved a proposal outlining a set of measures and criteria for monitoring the progress and achievements outlined in the schemed (Appendix II).

2.9 In May 2018, an interim report on the progress of the scheme was presented to the committee with a commitment to produce a full report on completion of the scheme at the end of March 2019.

2.10 This report provides an updated on the final position on the scheme against the set of measures and criteria set out on the evaluation report.

3 Results, Outcomes & Achievements

IMPROVEMENT IN CANCER CARE

For this element of the scheme, practices were asked to undertake the following; I. Increase the rate of uptake of bowel cancer screening.

II. Identify a cancer champion within each practice to lead on audits or a quality. Improvementactivity.

III. Identify learning points to improve care.IV. Offer 30 minute face to face reviews within 3-6 months of diagnosis.

3.1 Increase the rate of uptake of bowel cancer screening. 3.1.1 Regular bowel cancer screening has been shown to reduce the risk of dying from bowel cancer

by 16%. Bowel cancer screening aims to detect bowel cancer at an early stage (in people with no symptoms), when treatment is more likely to be effective. Bowel cancer screening can also detect polyps. These are not cancers, but may develop into cancers over time. They can easily be removed, reducing the risk of bowel cancer developing.

£0.20/pt was offered for this element in 2017-19, GP/Nurse/or other appropriately trained (and supported) healthcare professional were asked to follow up patients who have not taken up the invitation by offering an appointment or telephone call.

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Results

The table below shows the number of patients identified through the practice clinical system and /or through data received from the national bowel cancer screening team.

Patients between 60 -74 in West Kent identified and referred to screening programme Oct 2017 - March 2018 2742 April 2018 - March 2019 1686

Bowel screening activity from April 2009 to March 2018 for West Kent population compared to Kent, Surrey Sussex CCG’s average and England average.

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Data for 2018/19 will be published in December 2019.

https://fingertips.phe.org.uk

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https://fingertips.phe.org.uk/profile/general-practice/data#page/1/gid/1938132829/pat/120/par/E54000032/ati/165/are/E38000199/iid/92601/age/280/sex/4

3.2 Identify a cancer champion within each practice to lead on audits or a quality improvement activity.

3.2.1 The purpose of this was to ensure that all practice has a named contact for commissioners; this would also allow practices to focus on this area of care to improve outcomes for patients.

3.2.2 A total of £0.20/pt was offered to each practice to identify one partner or GP that has cancer leadership as part of their leadership role in the practice. The lead would ensure all GPs are fully aware of 2 week wait pathways and how this works by running a practice learning event where any areas of uncertainty regarding the 2ww referral process are discussed and clarified.

Results This was the most successful element of the scheme. All practice who signed up to the scheme identified a cancer champion who facilitated internal peer discussions and provided evidence to demonstrate achievement of this element.

3.3 Quality Improvement Project 3.3.1 For another £0.20/pt, the cancer champion was asked to lead on an audit or quality

improvement activity that related to patients with new diagnosis of cancer. This could be reviewing those that present with cancer in A&E as in previous years but we encourage practices to devise new ideas for audits. This should be informally presented in future Cluster PLT event to collate learning points and improve the care in this patient group that is related to patient with new diagnosis (excluding BCC). Targeted approach through audits and quality improvement programmes, shared learning at network events

Results All the practices participated in this element, a wide range of audit topics and quality

improvement projects were undertaken. In year 1, 17 practices shared at the PLT their audit/findings/peer discussion and a total was

16 practices. some shared with others yet to be shared at Cluster protected Learning Timeevents.

3.4 Offer 30 minute face to face reviews within 3-6 months of diagnosis. 3.4.1 Using Macmillan toolkit/guidelines/protocol, practices were asked to record and include an in-

depth review of patients’ concerns and expectations. Reviews could be conducted by Nurse or a GP or other appropriately trained (and supported) healthcare professional as per protocol. Improving cancer patient experience (and quality of life) is one of the three key ambitions in the report, Achieving world-class cancer outcomes: a strategy for England 2015-2020, published by the Independent Cancer Taskforce in July 2015. The Taskforce has set an ambition for continuous improvement in patient experience and to give it equal priority as clinical outcomes. Cancer Care Reviews (CCR) provides an opportunity to address patient’s holistic needs and ongoing support and information The CCR template devised by Macmillan was seen as a useful tool to use as part of the process however both patients and GPs did not want a tick box exercise. There is increasing evidence

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to suggest that patients who are supported and informed and can self-manage may achieve the best health and quality of life. With increasing numbers of people surviving their cancer diagnosis, cancer follow up in primary care is likely to start to resemble that of other long term conditions like COPD or Diabetes.

Data from the cancer data dashboard shows that for; Care transition: support from GP during treatment 2015

Percentage of responses to the question "Do you think the GPs and nurses at your general practice did everything they could to support you while you were having cancer treatment?" which were positive (excluding neutral responses). West Kent CCG average for all tumours = 63.5% (England range 44-75%) Definition: umber of positive responses divided by total of positive and negative responses.(i.e. neutral responses and non-responses are excluded from the denominator) Positive: Yes, definitely Negative: Yes, to some extent; No, they could have done more Neutral: My general practice was not involved

Increase in percentage of patients who report via the Cancer Patient Experience Survey having had a CCR A summary of any shared concerns from all case reviews to be discussed within the practice and learning shared at Cluster meetings. This element also attracted a £0.30/pt.

Results

Executive summary from the National Cancer Patient Experience Survey 2018 (NHS West Kent) CCG) 62% of respondents said that they thought the GPs and nurses at their general practice definitely did everything they could to support them while they were having cancer treatment.

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PATIENTS WITH A BMI OF 40 AND ABOVE

3.5 Identify all patients with a BMI of 40 and above

3.5.1 For £0.60/pt over the 2 years, practices were asked to contact patient with a BMI of 40 and above and offer an appointment with a GP , Nurse or other appropriately trained (and supported) healthcare professional to review their weight, Smoking Status, Health Check Status, Blood Pressure (hypertension), Recorded HBA1C in last 12months. Using motivational interviewing skills to engage patient in weight reduction programme e.g. “making every contact count”

Practices were asked to give a baseline of patients with a BMI>40 and above by end of November 2017.

• 84% practices signed up to the BMI element of the scheme.• A total of 6614 patients were identified by the practices• 22% of Practices have submitted evidence of patients reviewed/referred onto a weight

management programme.

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The table below shows a breakdown of the baseline data of the number of patients with a BMI of 40 and above per cluster.

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Cluster Number of patients identified

Cluster population , Percentage (%)

Sevenoaks 806 81,339 0.99% Tonbridge 1252 67,875 1.84% Tunbridge Wells 938 81,704 1.15% Maidstone Central 927 85,375 1.09% Maidstone Wide 720 68,343 1.05% Malling 1391 66,955 2.08% Weald 508 48,222 1.05% CCG Total 6542 499,813 1.31%

4 Finance

The weighting of funding across the two years was spread over 2years; £0.60 in year one and £0.90 in year two. Year Element 1: Cancer Element 2: BMI Total Allocated Funding 2018/19 £94,612.20 £73,466.00 £168,078.20 449100 2017/18 £103,127.00 £57,121.60 £160,248.60 298800

The table below shows a sum of payments made to practices on all elements of the scheme to date.

£0.00

£50,000.00

£100,000.00

£150,000.00

£200,000.00

£250,000.00

£300,000.00

£350,000.00

£400,000.00

£450,000.00

£500,000.00

2018/19 2017/18

Element 1: Cancer Element 2: BMI Funding Yet to be claimed

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Summary and conclusion

5.1 As evidence to the success of the improvement in Cancer care element, the most recent published figures shows that there had been a consistent year on year increase in the percentage uptake of bowel cancer screening across West Kent CCG. These increases since 2016/17 could be indirectly linked to the improvement measures practice have in place to address bowel cancer screening as a result of the introduction of this local improvement scheme. As part of this programme, all the GP practices that signed up to the scheme identified a cancer champion who facilitated internal peer discussions and provided evidence to demonstrate achievement of this element.

5.2 For the obesity element of this scheme, it is clear from the national data that the measures put in place by West Kent CCG in identifying obese patients has made a significant improvement to West Kent population.

5.3 In this scheme providing the opportunity for practices to capture patients at risk of other long term conditions such as hypertension and diabetes, the reduction in the Hypertension: QOF prevalence in 2018/19 figures is an example of the successful outcome of this scheme. And though we cannot directly link reduction in hypertension and blood pressure prevalence to obesity however there is evidence that obesity is linked to cardiovascular diseases which includes hypertension.

5.4 From the data presented in this paper, it can be broadly concluded that the scheme has had a positive impact on patient care, overall outcomes and experience. Even though, engagement in this year’s scheme has been poor compared to previous years, most practices found it a worthwhile exercise and an important area of focus. Particularly, the opportunity to identify a cancer lead and share good practice in house was a positively received and delivered.

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References

1. Right Care Commissioning for Value Where to Look pack NHS West Kent CCG January 2017.Available at https://www.england.nhs.uk/rightcare/wp-content/uploads/sites/40/2017/01/cfv-west-kent-jan17.pdf

2. Commissioning for Value Long term conditions pack, NHS West Kent CCG December 2016.Available at https://www.england.nhs.uk/rightcare/wp-content/uploads/sites/40/2016/08/cfv-west-kent-ltc.pdf

3. Cancer Care Review (CCR) Insight, opportunities and top tips April 2016 Produced by Yorkshire andHumber Clinical Network GP Leads Forum.

4. Public Health England Cancer data Dashboard Available athttps://www.cancerdata.nhs.uk/dashboard#?tab=Overview

5. https://www.ncpes.co.uk/reports/2018-reports/local-reports-2018/clinical-commissioning-groups-2018/4383-nhs-west-kent-2018-ncpes-report-99j/file

Appendix 1: Local Improvement Scheme 2017-19

Local Improvement Scheme 2017-19 - Fin

Appendix 2: Evaluation Proposal – Local Improvement Scheme 2017-19

Evaluation proposal - Local Improvement S

Appendix 3: Local Improvement Scheme 2017-19 Interim Report

NHS WKCCG Interim Report to PCCC for LI

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https://www.england.nhs.uk/rightcare/wp-content/uploads/sites/40/2017/01/cfv-west-kent-jan17.pdf

https://www.england.nhs.uk/rightcare/wp-content/uploads/sites/40/2017/01/cfv-west-kent-jan17.pdf

https://www.england.nhs.uk/rightcare/wp-content/uploads/sites/40/2016/08/cfv-west-kent-ltc.pdf

https://www.england.nhs.uk/rightcare/wp-content/uploads/sites/40/2016/08/cfv-west-kent-ltc.pdf

https://www.cancerdata.nhs.uk/dashboard#?tab=Overview

https://www.ncpes.co.uk/reports/2018-reports/local-reports-2018/clinical-commissioning-groups-2018/4383-nhs-west-kent-2018-ncpes-report-99j/file

https://www.ncpes.co.uk/reports/2018-reports/local-reports-2018/clinical-commissioning-groups-2018/4383-nhs-west-kent-2018-ncpes-report-99j/file

Version Final

1 Introduction

The purpose of this paper is to set out the proposals for the Local Improvement Scheme (LIS) for 2017‐19. The recommendation is based on the outputs from a task and finish group and feedback received from colleagues in primary care.

The strategic intent of the Local Improvement Scheme 2017‐19 is to support the delivery of NHS West Kent Clinical Commissioning Group’s (NHS WKCCG) objectives not delivered under the General Medical Services (GMS) and Personal Medical Services (PMS) contracts or other National and Local schemes available to general practice. Historically, Local Incentive Schemes (LIS) have been utilised within West Kent as a mechanism to reward quality improvements for a range of areas within primary care.

2 Principles, Aims and Objectives

The payment available for successful completion of all elements of the scheme will be £1.50per registered patient over a 2 year period.

The scheme is optional and comprises of two elements from which the practice can chooseto participate in one or both elements.

All elements will be focused on NHS WKCCG key outcome priorities No elements included in the LIS 2017‐19 will duplicate elements in other schemes or

national initiatives that could attract a double payment. Elements included in the LIS 2017‐19 are based on suggestions from practices worked up

and developed by Commissioning team members.

3 Finance

The LIS comprises of two QI initiatives with a delivery component in each of the two years. The weighting of funding across the two years has been split £0.60 in year one and £0.90 in year two, reflecting the effort required in each year but seeking to maintain a financial flow to practices in each year.

4 Participation in the scheme

The scheme will be available to all GP practices in NHS WKCCG. All practices are encouraged to participate in all elements of the scheme. In the event of a dispute over a practice’s entitlement and achievement the practice must

first discuss it with the Federation Cluster Lead. If a decision cannot be reached it will thenbe escalated to the CCG for a decision; this will include sharing all relevant data.

Each element is optional and independent of each other.

5 Process

A range of suggestions were submitted by practices and these were all considered. The most appropriate (according to fit with the strategic priorities of the CCG) and beneficial of these have been worked up into this proposed LIS for 2017/18 and 2018/19.

6 Proposal Financial Year 2017/19

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Version Final

2017/18 Element 1 Area of Improvement

Initiative Measures

Improvements in Cancer

Start October 17

INCREASE THE RATE OF UPTAKE OF BOWEL CANCER SCREENING (Occult blood screening)

i) GP/Nurse/or otherappropriately trained (andsupported) healthcareprofessional to follow uppatients who have not taken uptheir invitation to screening byappointment or telephone call.

ii) Patients will be re‐capturedinto the programme if thepatient contacts the Hub to geta new test kit. There is anational number that getsredirected to the relevant Hubwhich is 0800 707 60 60. TheHub covering the entire Southis located in Guildford.

Cancer Care Review read code 8BAV

Reward

2017‐18 £0.10

2017/18 measure

K&M_SIT_Top_tips_for_screening_2017.p

Number of patients contacted or referred to the bowel screening programme between 1st October 2017 to 31st March 2018


CANCER CHAMPION WITHIN EACH PRACTICE

i) Each practice to have onepartner or GP that has cancerleadership as part of theirleadership role in the practice.

ii) They should lead on cancerwithin the practice. Theyshould ensure all GPs are fullyaware of 2ww pathways andhow this works by running apractice learning event whereany areas of uncertaintyregarding the 2ww referralprocess are discussed andclarified.

2017/18 measure

Nomination of Cancer Lead Evidence of awareness and use of 2ww pathways. Cancer Lead to write brief notes and submit to CCG. [email protected]

Reward

2017‐18 £0.10 carrying-out-an-effective-ccr_tcm9-29761


i) Cancer champion to lead on anaudit or quality improvementactivity that is related topatients with new diagnosis ofcancer. This could be reviewingthose that present with cancerin A&E as in previous years butwe encourage practices todevise new ideas for audits.

2017/18 measure

Submission of audits, quality improvement activity or in depth review conducted between October to March 2018. Each practice should present learning at a Cluster meeting.

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Version Final

Reward

2017‐18 £0.10

ii) To be informally presented infuture Cluster PLT event tocollate learning points andimprove the care in this patientgroup that is related to patientwith new diagnosis (excludingBCC)


OFFER 30 MINUTE FACE TO FACE CANCER CARE REVIEW within 3‐6 months of diagnosis

i) Using Macmillantoolkit/guidelines/protocol.This should be recorded andinclude an in‐depth review ofpatients’ concerns andexpectations.

ii) Review can be conducted byNurse or a GP or otherappropriately trained (andsupported) healthcareprofessional as per protocol.

iii) Summary of any sharedconcerns from all case reviewsto be discussed within thepractice and learning shared atCluster meetings.

(Excluding BCC)

2017/18 measure

Number of patients diagnosed with cancer between 1st of October to 31st of March 2018

Number of patients who have been offered a face to face review between 1st of October to 31st of March 2018.

Number of patients who have had the 30 minute review between 1st of October to 31st of March 2018.

Submission of summary of common areas of concern.

Reward

2017‐18 £0.10

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Version Final

Element 2

Area of Improvement

Initiative Measures

Management of Obesity Start October 17

IDENTIFY ALL PATIENTS WITH A BMI OF 40 AND ABOVE

i) Each patient should be contacted by the Practice and offered an appointment with a GP , Nurse or other appropriately trained (and supported) healthcare professional , in which the following should be reviewed Weight

Smoking Status Health Check Status Blood Pressure (hypertension) Recorded HBA1C in last 12m

ii) Use motivational interviewing skills to engage patient in weight reduction programme e.g. “making every contact count”

Diabetic patients and Hypertensive patients may be captured opportunistically and where appropriate they should be referred to the following services: Health Check CBT/IAPT Smoking cessation Dietary advice Exercise on prescription Social prescribing initiatives Weight Management Services Practices can offer group sessions, walking, talking, listening and socialising sessions.

Sept 2017 baseline measure Obesity monitoring read code 66C Practices to submit number of patients eligible for each service by end of November 2017. On 31.3.18 the search will be rerun to identify improvements in status recording. The practice should submit a summary of the changes in recorded levels and how many patients have been referred to each service.

Reward 2017‐18 £0.20

Rerun search to identify level of impact as at 31.3.18 Feedback of audit results to CCG.

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Version Final

Financial Year 2018/19:

Element 1

Area of Improvement

Initiative

Improvements in Cancer Start October 17

INCREASE THE RATE OF UPTAKE OF BOWEL CANCER SCREENING (Occult blood screening)

i) GP/Nurse/or other appropriately trained (and supported) healthcare professional to follow up patients who have not taken up their invitation to screening by appointment or telephone call.

ii) Patients will be re‐captured into the programme if the patient contacts the Hub to get a new test kit. There is a national number that gets redirected to the relevant Hub which is 0800 707 60 60. The Hub covering the entire South is located in Guildford.

Reward 2018‐19 £0.10

2018/19 measure

K&M_SIT_Top_tips_for_screening_2017.p Number of patients contacted or referred to the bowel screening programme between 1st April 2018 – 31st March 2019



i) Each practice to have one partner or GP that has cancer leadership as part of their leadership role in the practice.

ii) They should lead on cancer within the practice. They should ensure all GPs are fully aware of 2ww pathways and how this works by running a practice learning event where any areas of uncertainty regarding the 2ww referral process are discussed and clarified.

2018/19 measure Nomination of Cancer Lead. Evidence of awareness and use of 2ww pathways. Cancer Lead to write brief notes and submit to CCG [email protected]

Reward 2018‐19 £0.10

carrying-out-an-effective-ccr_tcm9-29761


i) Cancer champion to lead on an audit or quality improvement activity that is related to patients with new diagnosis of cancer. This could be reviewing those that present with cancer in A&E as in previous years but we encourage practices to

Reward 2018‐19 £0.10

2018/19 measure

Submission of audits, quality improvement activity or in depth review conducted between April 2018 to March 2019.

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Version Final

devise new ideas for audits. ii) To be informally presented in

future Cluster PLT event tocollate learning points andimprove the care in this patientgroup that is related to patientwith new diagnosis (excludingBCC)

Each practice should present learning at a Cluster meeting.


OFFER 30 MINUTE FACE TO FACE CANCER CARE REVIEW within 3 – 6 months of diagnosis:

i) Using Macmillantoolkit/guidelines/protocol.This should be in depth reviewpatients’ concernsexpectations.

ii) Review can be conducted byNurse or GP or otherappropriately trained (andsupported) healthcareprofessional as per protocol.

iii) Summary of any sharedconcerns from all case reviewsto be discussed within thepractice and learning shared atCluster meetings.

2018/19 measure

Number of patients diagnosed with cancer between 1st of April 2018 to 31st of March 2019

Number of patients who have been offered a face to face review between 1st of April 2018 to 31st of March 2019.

Number of patients who have had the 30 minute review between 1st of April 2018 to 31st of March 2019.

Reward

2018‐19 £0.20

Element 2

Area of Improvement

Initiative Measures

Management of Obesity

Start October 17


i) Each patient should becontacted by the Practice andoffered an appointment with aGP , Nurse or otherappropriately trained (andsupported) healthcareprofessional , in which thefollowing should be reviewed

WeightSmoking StatusHealth Check StatusBlood Pressure (hypertension)Recorded HBA1C in last 12m

On 31.3.18 the search will be rerun to identify improvements in status recording.

The practice should submit a summary of the changes in recorded levels and how many patients have been referred to each service.

Reward

2018‐19 £0.40 Rerun search to identify level of impact as at 31.3.19

Feedback of audit results to CCG.

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Version Final

ii) Use motivational interviewingskills to engage patient inweight reduction programmee.g. “making every contactcount”

Diabetic patients and Hypertensive patients may be captured opportunistically and where appropriate they should be referred to the following services:

Health Check CBT/IAPT Smoking cessation Dietary advice Exercise on prescription Social prescribing initiatives Weight Management Services

Practices can offer group sessions, walking, talking, listening and socialising sessions.

Please contact the LIS Co‐ordinator if you have any queries.

Sara Trimmer Medicines Optimisation – Primary Care Wharf House, Medway Wharf Road Tonbridge, Kent TN9 1RE Phone: Direct Line (01732) 376114

Office : (01732) 375200 Mobile: Mobile 07920 577556

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Evaluation Proposal for 2017‐19 Local Improvement Scheme.

1 Introduction

The purpose of this paper is to set a proposal for evaluating the progress and achievement of the Local Improvement Scheme (LIS) for 2017‐19.

The strategic intent of the Local Improvement Scheme 2017‐19 is to support the delivery of NHS West Kent Clinical Commissioning Group’s (NHS WKCCG) objectives not delivered under the General Medical Services (GMS) and Personal Medical Services (PMS) contracts or other National and Local schemes available to general practice. Historically, Local Improvement Schemes (LIS) have been utilised within West Kent as a mechanism to reward quality improvements for a range of areas within primary care.

A small task and finish group was set up to develop the LIS. The group worked through a number of suggestion made by primary care clinicians on possible areas to improve patient care, outcomes, experience and costs to the CCG. The suggestions were mapped against tools utilised by CCG commissioners to identify areas of opportunity to improve patient outcomes and reduce spend such as the Right Care data packs and Cancer Data Dash Board.

The Right Care packs (previously known as Commissioning for Value Packs) provides the commissioning system with data, evidence, tools and practical support around spend, outcomes and quality, the programme can help clinicians and commissioners transform the way care is delivered for their patients and populations and reduce variation in health inequalities. The Right Care pack compares our CCG to the 10 most demographically similar CCGs. The analysis in the pack is based on a comparison with your most similar CCGs. The latest pack issued in January 2017 highlighted the following areas of opportunity for West Kent CCG below in table 1. Table 2 gives a further breakdown of the specific areas of opportunity for quality improvement and spend.

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The opportunities quoted above outlines the potential improvements (in terms of both reduced expenditure and lives saved) if the CCG were to perform at the average of the similar 10 and best five of the similar 10.

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2 Initiatives The two areas chosen and supported by data were as follows;

A Improvement in cancer care

Cancer is a major cause of death, accounting for around a quarter of deaths in England. More than 1 in 3 people will develop cancer at some point in their life. In January 2011 the Government published Improving Outcomes ‐ a Strategy for Cancer. This document sets out how the Government plans to improve cancer outcomes, including improving survival rates through tackling late diagnosis of cancer.

Screening is a way of testing healthy people to see if they show any early signs of cancer. Bowel cancer screening can save lives. Screening aims to detect bowel cancer at an early stage, when treatment has the best chance of working. The test can also find polyps (non‐cancerous growths), which might develop into cancer. Polyps can easily be removed, to lower the risk of bowel cancer. In England, Wales and Northern Ireland people over the age of 60 are invited to take part in bowel cancer screening, whereas in Scotland, screening starts from age 50. Screening is every two years until the age of 75.

Evaluation Proposal The measures listed in the table below will be used in monitoring the progress and achievements of this element

Element 1 Area of Improvement

Initiative Rationale and Expected Outcomes Measures Dates & Milestones


Start October 17

INCREASE THE RATE OF UPTAKE OF BOWEL CANCER SCREENING

Regular bowel cancer screening has been shown to reduce the risk of dying from bowel cancer by 16%. Bowel cancer screening aims to detect bowel cancer at an early stage (in people with no symptoms), when treatment is more likely to be effective. Bowel cancer screening can also detect polyps. These are not cancers, but may develop into cancers over time. They can easily be removed, reducing the risk of bowel cancer developing.

Bowel ‐ Screening uptake (LA) 2015

Data from local screening team

Number of non‐responders recorded in April ‐ August 2017 = 20,724

Number of non‐responder recorded in April 2018

Number of Non responder recorded in April 2019.

Survival data for colorectal cancers Data from practices

October 2017 Baseline data for bowel screening uptake rates and non‐responders

March 2018 – non‐responders contacted

March 2019 – 2nd years data on non‐responders and

Reward

2017‐18 £0.10 2018‐19 £0.10

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% of people eligible for bowel screening who were screened Maidstone 62.7 Tonbridge & Malling 61.3 Tunbridge Wells 60.5% Sevenoaks 62% England 57.1%

Early detection and diagnosis of bowel cancer Reduced mortality from bowel cancers Increase in one year survival rate Reduction in non‐responders Increase in percentage uptake

Number of patients contacted or referred to the bowel screening programme between 1st October 2017 to 31st March 2018 Indicator based on national published data which is 2 years behind therefore we expect to see improvement in survival rates from 2019/20data for 31 March will be published annually ‐ data also available monthly via Health and Social Care Information Centre Open Exeter system (restricted access).

number contacted April 2020 & 2012 National data on cancer detection and survival rates

2017‐18 £0.10 2018‐19 £0.10


This becomes an area of focus for the practices to improve outcomes for patient outcomes Named contact for commissioners within the practice

2017/18 measure Cancer lead identified for each practice 59 Cancer leads

Lead identified and submission of audit or review by March 2018

2017‐18 £0.10 2018‐19 £0.10

Cancer champion to lead on an audit or quality improvement activity that is related to

Targeted approach through audits and quality improvement programmes Shared learning at network events Improved survival rates measures related to

Under 75 mortality rate Under 75 mortality rate under cancers

considered preventable

Audits, quality improvement activity or in depth review conducted between October to March 2018. 2018/19 Each practice should present learning at a Cluster meeting. A summary of learning shared at the cluster meetings will be collated and used shared with relevant commissioning managers.

March 2019 Presentation by practice at Cluster meetings

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OFFER 30 MINUTE FACE TO FACE CANCER CARE REVIEW within 3‐6 months of diagnosis

Improving cancer patient experience (and quality of life) is one of the three key ambitions in the report, Achieving world‐class cancer outcomes: a strategy for England 2015‐2020, published by the Independent Cancer Taskforce in July 2015. The Taskforce has set an ambition for continuous improvement in patient experience and to give it equal priority as clinical outcomes.

Cancer Care Reviews (CCR) provides an opportunity to address patient’s holistic needs and ongoing support and information The CCR template devised by Macmillan was seen as a useful tool to use as part of the process however both patients and GPs did not want a tick box exercise. There is increasing evidence to suggest that patients who are supported and informed and can self‐manage may achieve the best health and quality of life. With increasing numbers of people surviving their cancer diagnosis, cancer follow up in primary care is likely to start to resemble that of other long term conditions like COPD or Diabetes. Evidence suggests some people living cancer are followed up more frequently than others and therefore there are inconsistencies across tumour sites.

Data from the cancer data dashboard shows that for; Care transition: support from GP during treatment 2015

West Kent CCG average for all tumours = 63.5% (England range 44‐75%)

Definition Percentage of responses to the question "Do you think the GPs and nurses at your general practice did

2017/18 measure

Number of patients diagnosed with cancer between 1st of October to 31st of March 2018

Number of patients who have been offered a face to face review between 1st of October to 31st of March 2018.

Number of patients who have had the 30 minute review between 1st of October to 31st of March 2018.

Submission of summary of common areas of concern raised by patients during CCRs.

Frequency and data lag Annual, reporting patient experience over a three month period with a lag of around 6 months.

March 2018

report from practices on the number of cancer diagnosis from October

2017‐March 2018 Number of CCRs undertaken by Practices

March 2019 report from practices on number of cancer diagnosis between April 2018‐ March 2019

Number of CCRs undertaken by practices

Report of common issues raised by patients

Report on why patients did not take up CCR’s or why they were not offered.

Reward

2017‐18 £0.10

2018‐19 £0.20

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everything they could to support you while you were having cancer treatment?" which were positive (excluding neutral responses). Methodology Number of positive responses divided by total of positive and negative responses. (i.e. neutral responses and non‐responses are excluded from the denominator) Positive: Yes, definitely Negative: Yes, to some extent; No, they could have done more Neutral: My general practice was not involved Increase in percentage of patients who report via the Cancer Patient Experience Survey having had a CCR

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B Management of obesity

The key aim of this element of the scheme is to provide an opportunity for practices to focus on identifying patients who are obese and offer targeted interventions when appropriate. This also creates the opportunity for practices to capture patients at risk of other long term conditions such as hypertension and diabetes. In England, most people are overweight or obese. This includes 61.9% of adults and 28% of children aged between 2 and 15. People who are overweight have a higher risk of getting type 2 diabetes, heart disease and certain cancers. The Commissioning for Value Pack for West Kent CCG published in December 2016 indicated that 63.4% of the population in West Kent are obese compared to and England Average of 64.6%.

Evaluation Proposal The measures listed in the table below will be used in monitoring the progress and achievements of this element.

Area of Improvement

Initiative Rationale & Expected Outcomes Measures Key milestones

Management of Obesity

Start October 17

Reward

2017‐18 £0.20

2018‐19 £0.40


Diabetic patients and Hypertensive patients may be captured opportunistically and where appropriate they should be referred to the following services:

Health Check CBT/IAPT Smoking cessation Dietary advice Exercise on prescription Social prescribing initiatives Weight Management Services

Practices can offer group sessions, walking, talking, listening and socialising sessions.

Commissioning for Value Pack for LTC Dec 2016

Percentage of adults classified as overweight or obese (estimated prevalence) = 63.4% (England Ave 64.6%)

Reported to Estimated prevalence of Hypertension (%) = 56.4% (1855 pts)

Observed prevalence compared to Estimated prevalence in adults (%) = 72.4% (1845 pts)

West Kent CCG 2015‐16 QOF Obesity recorded prevalence = 8.39%

Diabetes recorded prevalence = 5.63%

Recorded MORBID obesity rate at practice level using Read term (code C3808) as problem Search for latest BMI with value 40 or more Obesity monitoring read terms (codes 66C..) for those with morbid obesity and BMI 40+

Recorded obesity rate at practice level

The data on patients eligible for weight management services will be shared with the providers of weight management services commissioned by the district and borough councils

November 2017

baseline data for obesity recorded by practices using the Obesity monitoring read code 66C

March 2018 & 2019

Recorded obesity levels

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Hypertension recorded prevalence = 13.69%

Increase in the number of patients offered advice or sign posted to support e.g. primary care based support, OneYou or tier 2 or 3 weight managementservices

Increase in obesity recordings on practice system and QOF

QOF recorded prevalence for 1. Obesity2. Diabetes3. Hypertension

to demonstrate improvement in recorded rates and narrowing of the gap between expected and recorded

Number of patients identified

Number of patients offered support advice, sign‐posting or referral

November 2017 Baseline QOF data for 2016‐17

November 2018 QOF data for 2016‐17

November 2019 QOF Data for 2017‐18

November 2020 QOF data for 2018‐19

Data from Providers of Weight Management Services for Y1 & 2

Number of patients referred to weight management service

Number of patients enrolled

Completion rate

Percentage weight loss

June 2018

June 2019

Impact on NHS Health Checks, CBT/IAPT and Smoking cessation rates will be measured at the end of year 1 & 2 of the scheme.

Interventions such as Dietary advice, exercise on prescriptions, social prescribing interventions are more subjective therefore difficult to measure.

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3 Next Steps

The measures outlined in the proposal will be monitored on a regular basis by the LIS coordinator. An interim evaluation report will be provided to the committee in June 2018 with a full evaluation report at the end of June 2019.

4 Recommendation

The committee is asked to consider the proposal outlined as a set of measures to monitor the progress and achievements of the 2017‐19 Local Improvement Scheme and agree on next steps.

5 References

Right Care Commissioning for Value Where to Look pack NHS West Kent CCG January 2017. Available at https://www.england.nhs.uk/rightcare/wp‐content/uploads/sites/40/2017/01/cfv‐west‐kent‐jan17.pdf

Commissioning for Value Long term conditions pack, NHS West Kent CCG December 2016. Available at https://www.england.nhs.uk/rightcare/wp‐content/uploads/sites/40/2016/08/cfv‐west‐kent‐ltc.pdf

Cancer Care Review (CCR) Insight, opportunities and top tips April 2016 Produced by Yorkshire and Humber Clinical Network GP Leads Forum. Public Health England Cancer data Dashboard Available at https://www.cancerdata.nhs.uk/dashboard#?tab=Overview

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Patient focused Providing quality, improving outcomes

Local Improvement Scheme 2017‐19 Interim Report

DATE May 2018

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Purpose The purpose of the report is to provide an interim update to the Primary Care Co‐Commissioning Committee (PCCC) on the 17‐19 Local Improvement Scheme (LIS).

Introduction and background

The 2017‐19 LIS (Appendix 1) was ratified on the 5th of September 2017 following a proposal from NHS West Kent CCG primary care team. Recommendations for the scheme were based on the outputs of a task and finish group and feedback received from colleagues in primary care. The scheme was launched to practices in October 2017.

The scheme comprises of two Quality Improvement (QI) initiatives with a delivery component in each of the two years 2017/18 and 2018/19. The weighting of funding across the two years has been split £0.60 in year one and £0.90 in year two, reflecting the effort required in each year but seeking to maintain a financial flow to practices in each year.

The scheme is available to all GP practices in NHS WKCCG. The payment available for successful completion of all elements of the scheme 2017/19 will be £1.50 per registered patient over a 2 year period. No elements included in the LIS 2017‐19 duplicate elements in other schemes or national initiatives that could attract a double payment.

In November 2017, the committee considered and approved a proposal outlining a set of measures for monitoring the progress and achievements of the 2017‐19 Local Improvement Scheme and agree on next steps. Appendix 2. This interim report is based on the measuresdescribed in the evaluation proposal and the information received to date from practices.

Components of the scheme

1. Improvement in cancer care

Practices were required to Increase the rate of uptake of bowel cancer screening. Identify a cancer champion within each practice to lead on audits within the practice

or a quality improvement activity. Identify learning points to improve care. Offer 30 minute face to face reviews for patients within 3‐6 months of their

diagnosis.

Update on progress

To date, first 6 months of the rolling 18 month scheme: 92% of practices have signed up for this element of the scheme.

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All the practices who have signed up have identified a cancer champion (all GPs) 25% of practices have submitted evidence of audits undertaken by their practice.

Evidence from the remaining 75% is still awaited. Practices have submitted information on the number of face to face cancer reviews

undertaken. This data is yet to be analysed.

One of the key challenges of this element is convincing patients to take up bowel screening; this may be helped by a local campaign which mirrors the national campaign currently being promoted through social media and television.

The scheme is on‐going and practices have shown engagement; feedback from practices indicates that there will be a positive outcome for patients. Practices have informed that internal audits show the value in the scheme in both confirming and excluding cancer diagnosis with patients.

2. Management of obesity

Identify all patients with BMI of 40 and above (diabetic patients and hypertensivepatients may also be captured opportunistically and where appropriate referred onto other services including weight management services).

Practice Participation

Practices were asked to give a baseline of patients with a BMI of 40 and above by end of November 2017.

84% practices signed up to the BMI element of the scheme. A total of 6614 patients were identified by the practices 22% of Practices have submitted evidence of patients reviewed/referred onto a

weight management programme.

Table below shows a breakdown of the number of patients with a BMI of 40 and above identified per cluster.

Cluster Number of patients identified

Cluster population , Percentage (%)

Sevenoaks 806 81,339 0.99%

Tonbridge 1252 67,875 1.84%

Tunbridge Wells 938 81,704 1.15%

Maidstone Central 927 85,375 1.09%

Maidstone Wide 720 68,343 1.05%

Malling 1391 66,955 2.08%

Weald 508 48,222 1.05%

CCG Total 6542 499,813 1.31%

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The LIS was launched in October 2017; even though practices were asked to refer patients on at the start of the scheme, practices decided to hold onto referrals until the 1st of January 2018 to coincide with patients being in a better mind‐set immediately after Christmas to want to lose weight and be engaged with a lifestyle improvement programme.

One of the key challenges of this element of the scheme has been the volume of patients referred to the borough and district councils’ weight management programmes. The CCG team have been in constant dialogue with the councils to ensure adequate capacity is created to cope with the demand.

Some practices perceived that contacting patients with a high BMI was too direct and may have a knock on effect on the doctor‐patient relationship. Therefore, some practices have used a more targeted approach of focusing on high risk groups with co‐morbidities such as invitations to chronic disease reviews where lifestyle advice and appropriate signposting is also covered; obesity monitoring and follow up is part of this review.

Practices plan to address other high BMI patients gradually during future contacts. Alerts have been set up on clinical systems to remind practices of the importance of addressing obesity.

Summary and conclusion

Feedback from practices indicates a good level of engagement with the 2017‐19 scheme. Practices are progressing with the requirements set out in the scheme. A full report on the outcomes of the scheme based on the evaluation proposal agreed by the committee in November 2017 and the financial reimbursement to practices will be presented to the committee in the second quarter of the 2019‐20 financial year.

Appendix 1: Local Improvement Scheme 2017‐19

Local Improvement Scheme 2017-19 - Fin

Appendix 2: Evaluation Proposal – Local Improvement Scheme 2017‐19

Evaluation proposal - Local Improvement S

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Date: 24 March 2020

Reporting Officer: Ruth Wells Agenda Item: 15 Lead Director: Gail Arnold Version: 1.0 Report Summary:

Following a meeting between the partners of The Mote Medical practice and the CCG primary care lead director - where their historic, current and future positions were evaluated - the Mote Medical Practice has now asked the CCG to consider an application for another provider to take over delivery of GMS services from their Loose branch site.

They have historically and currently continue to suffer from long term workforce recruitment issues which are compounded with the need to staff two sites. This poses a risk to their ability to deliver a safe quality service to their registered population. One option offered to them to address these difficulties was to work with them to reduce the number of patients they have registered. From this came the suggestion of exploring the potential of another practice taking over their branch surgery.

If another provider were to take over the Loose Branch and its associated 3000 ( circa ) patients it is believed that The Mote Medical practice is sustainable on the reduced list size.

Primary Care Co-commissioning Committee: Proposal for continuation of services from Loose branch

surgery

This paper is for: For information and agreement in principle of the approach

Recommendation: It is the recommendation that the committee considers agreeing to this approach as a hybrid application of existing merger and list dispersal policies. Furthermore it allows general practice to retain a site and service in an area identified as necessary to meet the needs of the population.

For further information or for any enquiries relating to this report please contact: Ruth Wells, Senior Primary Care Development Manager

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The purpose of this paper is to inform West Kent CCG Primary Care Commissioning Committee of an application from Greensands Health Centre to take over the 3000 patients registered for whom the Loose branch surgery is their nearest site. This ensures service continuity and avoids a branch closure. Closure of a branch surgery is a significant change for registered patients and there is an opportunity to avoid that albeit they would experience a change in practice provider.

Following a review of the consequences and implications of the Mote surgery potentially applying to close their Loose branch, the CCG commenced conversations with local practices to seek an alternative alternative service provider in that place. There were no expressions of interest from the neighboring practices other than Greensands.

The financial implications of this are £130893 and detailed further in the Payment Proposal appendix.

This is a hybrid payment proposal based on the merger principles to recognise the legal and operational costs plus the elements of the list dispersal that support new patient registration and the associated reviews.

A pure list dispersal supports the new provider with an enhanced GMS payment of 1.4 usual GMS fee.

Due to the fact that this list dispersal is technically enabled by bulk transfer rather than re-registration and the payment proposal includes new patient review funding, in this instance it does not attract the enhanced GMS.



D – Improve Service Quality and patient safety

E – Deliver sustainable Finance

F – Ensure robust governance


NHS England Primary Medical Care Policy and Guidance Manual (PGM) 2019

Standard General Medical Services Contract

NHS England Standard Operating Policies and Procedures for Primary Medical Services


There is a risk if this proposal is not supported that the Loose Branch will close resulting in list dispersal

Resource implications: There are cost considerations based on the merger and list

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dispersal policies – noted in the appendix Legal implications including equality and diversity assessment

Legal advice has been sought from Capsticks who advise that technically this is a closure and an opening however from a patient communication perspective it is a continuation of services albeit with another provider. Patients retain the choice to remain with Mote Medical Centre and receive services from The Mote’s main site or register with Greensands and continue to receive their care at the Loose branch site. Further advice is awaited to guide the process for service procurement if applicable.


Not applicable


Not applicable


See appendix

Report history: PCOG 25/2/2020

Appendices

Loose Branch Public Involvement Assessme

Loose Branch Impact Assessment V 2 FINAL

Loose Branch Payment proposal FINA

Next steps: The committee is asked to consider agreeing to the approach of Greensands Health Centre taking over the Loose Branch and its patient population and adopting principles contained in the merger and list dispersal policies to govern how this is achieved.

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March 2020

NHS West Kent CCG

Practice Information

Contract Information

The Mote Medical Practice (St Saviours Road, Maidstone, ME15 9FL) and the Loose branch surgery (1 Boughton Lane, Loose, ME15 9QJ) have a combined GMS contract with one organisation code (G82076), the contract is held by four GP partners.

The practice received a GOOD rating on the most recent CQC visit in July 2019.

Patient demographics

The practice list size is 11,008 as at 1st January 2020. Mote Medical Practice - 8,052, Loose Branch Site – 2,956.

Both the main and branch surgeries are situated outside Maidstone town centre with twelve other practices (seventeen sites) within 4 miles of the Loose Branch Surgery. The map below shows all practices within this area.

The CCG analysis of the postcodes of the registered patients (using a non-patient identifiable data extract provided by the practice) shows that most of the patients reside in the me15 9

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NHS West Kent CCG

and me15 6 postcode areas; me15 9 5 is the postcode area in which both the main Mote site and the Loose branch site is located.

Informed by the use of a mapping tool we can see that of the 2,483 patients who regularly use the Loose branch:

are located within an area that the Loose site on Boughton Lane is closer than the main Mote site on St Saviours Road, Maidstone, ME15 9FL. 469 patients are closest in distance to the main Mote site, yet regularly use the Loose practice site. It is worth noting that 187 patients (of the 2,956 Loose site patients) are closest in distance to the Greensand Health Centre in Coxheath rather than the Loose site.

The heat map below uses the information in the above table and shows the spread of the patients registered with Loose site.

The following Practices’ catchment areas cover the majority of the 2,956 patients:

• The College Practice• Northumberland Court• Brewer Street Surgery• Walls Avenue Surgery

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March 2020

NHS West Kent CCG

• Albion Place Practice• Greensand Health Centre• Orchard Surgery (Langley)

Practice Opening Hours A breakdown of the practice opening hours for the two sites is shown in table 1.

Mote Medical Practice Loose Surgery (Branch Site)

Core Opening Hours Core opening hours

Monday 08.30 – 18.00 08.30 – 17.30 Tuesday 08.30 – 18.00 08.30 – 17.30 Wednesday 08.30 – 18.00 08.30 – 17.30 Thursday 08.30 – 18.00 08.30 – 13.30 Friday 08.30 – 18.00 08.30 – 13.30 Saturday Closed Closed Total 47.5 hours 37 hours

Staffing Levels The practice currently operates with the following clinical staff as detailed in table 2.

Table 2 – Clinical staffing Clinical staff Clinical Staff

GP 6 Practice Nurse 3 Health Care Assistant 2 Pharmacist 0

To summarise the GP resource: • There are 6 GPs: who provide a total of 35 sessions per week across both sites• 9 of the 35 sessions are provided at Loose Road Surgery• 26 of the 35 sessions are provided at Mote’s main site at St Saviour’s Road

Contract, Regulation and Legislation Implications

GMS Contract and Regulations

There is nothing specifically stipulated within the GMS Contract or Regulations with regards to the opening or closure of branch surgeries.

However, Part 26, clause 26.1 requires the provider to obtain agreement in relation to changes to the services provided. Therefore agreement must be sought and a variation issued before any changes can be made to the premises sites in which services can be delivered.

Also as stated in paragraph 2.5 of this report, the Primary Medical Care Guidance Manual

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encourages practices to engage in an early dialogue with the commissioners and to ensure the needs of the population are met and that commissioners comply with the section 13Q duty to involve patients for any significant change in service.

Dispensing Rules The practice does not offer medicines dispensing services.

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Access and Transportation

Road map of the journey from Loose Surgery (Boughton Lane) to Mote Medical Centre (St Saviour’s Road) by car (Google maps 05/02/20)

Parking is available at Mote Medical main site (33 parking spaces)

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NHS West Kent CCG

Road map of the journey from Loose Surgery (Boughton Lane) to Greensand Health Centre (Coxheath) by car (Google maps 05/02/20)

Parking is available at Greensand Health Centre (13 parking spaces)

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Bus services from Loose Surgery (Boughton Lane) to Mote Medical (St Saviours Road) is via 2 bus journeys – number 82 (every 10 mins) & 89 (every 20 mins)

Bus service from Loose Surgery (Boughton Lane) to Greensand Health Centre (Coxheath) is via 1 bus – number 89 (every 20 mins)

Conclusion It is the recommendation of the CCG that the services from the Loose Branch be retained in the local system by allowing another provider, Greensands Health Centre, to take over the delivery of GMS services at the Loose Branch site. However for patients who choose to remain registered with The Mote and visit its main site the CCG is satisfied that there is adequate public transport to, and parking at, that site.

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Appendix 4: Section 13Q Duty Public Involvement Assessment Form

Step 1 - Details of the commissioning activity Describe the commissioning activity:

Greensands proposal to take over patients registered with Mote Medical Practice and looked after at their Loose branch to ensure service continuity and avoid branch closure. Closure of a branch surgery is a significant change for registered patients. Following a review of the consequences and implications of Loose branch closing, the CCG commenced conversations with local practices for alternative service provision. The proposal is in line with the premises strategy to support additional growth and transformation plan for the area.

Step 2 – Identify type of commissioning activity Type of activity: ☐Planning ☐Proposals for change ☒Operational decision

Step 3 – In respect of proposals for change or operational decisions, assess the impact on service users If the plans, proposals or decisions are implemented, would there be:

☐An impact on the manner in which the services are delivered to the individuals at the point whenthey are received by users? ☐Yes ☒No☐An impact on the range of health services available to users? ☐Yes ☒NoExplain why you have answered yes or no to the above:

Service proposal (Greensands): The surgery will open from 8.30am to 5.00pm Monday to Friday with all evening clinics being delivered from Stockett Lane site, this may change over time but this would be the initial plan. The plan is to deliver all core services under the GMS contract from the branch. The practice feels that this location could develop over time to become a PCN hub. It is geographically central to the PCN and would enable easy access for patients from all of the practices in the PCN. It will ease pressure on premises utilisation; Greensands are struggling on space within their current two buildings and this will help to have a third building to locate a range of their current staff (clinical and non-clinical) as well as some additional new team members.

Step 4 – section 13Q duty Does the section 13Q duty apply to the activity? ☐ Yes ☒ No Explain why you have answered yes or no to the above: If yes,

(a) identify any existing arrangements to involve the public which are already in place (nationalor local involvement initiatives):

(b) whether it is considered necessary to make further arrangements for this activity and if sowhat these will be:

Confirm whether a further assessment needs to be carried out in future and, if so, when or in what circumstances that will be carried out: Review proposal with comms and engagement team (clarify patient involvement activities required

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by the CCG and practice.

Name: Funmi Owalabi

Job Title: Head of Contracting Primary Care

Date: 13/3/2020

If you are unsure as to the answer to any of these questions, seek advice from the relevant team in your region or the Public Participation Team in the national support centre.

Completed assessment forms must be retained and will be required for reporting and monitoring purposes.

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Financial Proposal

The payment proposed is to be based on the principles laid out within the CCG’s Merger Policy and that for List Dispersal.

Payments will be made up as follows:

Payment to Practice

1.List Dispersal

£20.15 per new patient registration (new patient uplift exclusive) £12.00 for new patient reviews (for all patients over 40 years old and those under the age of 40 who have a long term condition) £7.85 per patient for medication reviews for all those patients on 4 or more drugs

These payments have been agreed to cover provision of GP services in full, including, but not limited to, GP consultations, nursing consultation, prescription management and administration support. Payment includes cover on Monday to Friday 08.00 – 18.30 excluding Bank Holidays.

2. As per the Merger Policy

To recognise that as the new provider is retaining the outgoing provider’s site this has some features of a merger as legal costs will be incurred for the lease and operational costs for new IT system integration, signage, medical records etc. Total Funding Proposal breakdown ( to the practice )

Contribution towards Legal Fees £ 5,000.00 Project Management and Operational Costs £ 10,000.00

Patient Registration Fee £ 59,563.40

Patient Reviews (over 40 and LTC) £ 21,924.00

Medication Reviews £ 6,405.60 £ 102,893.00

List size (Loose patients) = 2956 Patients over 40 = 1758 Patients on 4 or more meds = 816 Patients with long term conditions (based on QoF domains) = 69

Direct CCG Costs IT clinical system switch £25000 PCSE patient letters £3000

Total Costs £130893

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Date: 24 March 2020 Reporting Officer: Alison Burchell Agenda Item: 16 Lead Director: Gail Arnold Version: 1.0 At the PCCC meeting in October 2019 support was provided for the Stage 1 premises proposal submitted by the three practices currently located in Cranbrook; Orchard End Surgery, The Old School Surgery and the The Crane Surgery.

The Stage 1 proposal was for one new general practice building in Cranbrook to replace 3 existing practice buildings. The proposal detailed that a site specific options appraisal would be undertaken; this has now been completed and the output shared with the CCG.

This purpose of this report is to evidence and provide assurance that the process has been undertaken, to summarise the key points along the preferred site and to seek CCG support to enable the practices to take forward the detailed discussions as part of the development of Stage 2 business case.

Due to the timing of the next PCCC meeting being towards the end of March it was agreed that the paper would be circulated to PCCC for consideration to enable the project to move forward.


Cranbrook Practices: General Practice Premises Development – Preferred Site


Recommendation: The Primary Care Commissioning Committee is asked to note that:

• Following virtual review in February 2020 note the PCCCsupport provided for the preferred site option to enable thepractices to progress plans to Stage 2.

For further information or for any enquiries relating to this report please contact:

Alison Burchell, Programme Director (Primary Care Strategic Planning)

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A. Implementation of Mapping the Future BlueprintB. Service quality and patient safety


Strategic Goal A&C: Failure to make the strategic changes needed to deliver Mapping the Future and the Sustainability and Transformation plan (STP) may result in a local healthcare system that

- is unsustainable in the long term- is unable to ensure high quality accessible services forlocal people- does not deliver improved outcomes and reducedInequalities


All developments approved at Stage 1 must progress through Stage 2 and 3 of the process set out in the General Practice Premises Development Policy. All developments will be at risk prior to Stage 3 approval without a financial consequence to the CCG.

Resource implications: There are no financial resource implications for the CCG at Stage 1. A full financial appraisal and District Valuer value for moneyinterim report will be provided at Stage 2.


None


Has an equality assessment been undertaken?

An equality assessment will be undertaken by the practice during the next phase of the work


None


The Stage 1 proposal highlighted the patient engagement and communication activities that will be incorporated into their plan during the next phase of the work

Report history: Stage 1 Proposal supported PCCC October 19

Appendices None

Next steps: Practices continue to develop plans to inform a Stage 2 submission.

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West Kent CCG Front Sheet

Cranbrook Practices: General Practice Premises Development – Preferred Site

1. Background

1.1. At the PCCC meeting in October 2019 support was provided for the Stage 1 premises proposal submitted by the three practices currently located in Cranbrook; Orchard End Surgery, The Old School Surgery and The Crane Surgery.

1.2. The Stage 1 proposal was for one new general practice building in Cranbrook to replace 3 existing practice buildings. The proposal detailed that a site specific options appraisal would be undertaken; this has now been completed and the output shared with the CCG.

1.3. The options appraisal process forms part of the strategic and operational level assessment for any premises project and involves a series of discussions between the practice/ practice professional adviser and site owners and between the practice/professional adviser and the CCG. The options appraisal document provided to the CCG summarises the outputs of the assessment undertaken.

1.4. This purpose of this report is to evidence and provide assurance that the process has been undertaken, to summarise the key points along the preferred site and to seek CCG support to enable the practices to take forward the detailed discussions as part of the development of Stage 2 business case.

2. Summary Options Appraisal

The detailed options appraisal contains confidential information and some site information has therefore been anonymised below, this is summarised as follows:

Strengths and opportunities Weaknesses and Threats

Site 1 Land allocated in Draft Local Plan forpossible inclusion of medical centre

Site owned by Parish Council – giftedland for community use

Town Centre location

Free town centre parking

Accessible by public transport

Timescale for delivery - site ownerready to proceed

Density of development maylimit scope to extend in thefuture to growth beyond a listsize of c12,000 (expected toincrease to in next 10-15 years)

Affordability - plans require fullwork up and assessment to testfully.

Assurance will be required

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Strengths and opportunities Weaknesses and Threats

Site supports future populationgrowth

Supports delivery of GMS and PCNservices and changing model of care(including digital transformation andon line consultations )

Potential for close working with othercommunity based services in the samedevelopment

through next phase of discussions regarding delivery model and experience for medical centre - informs affordability and overall VFM assessment.

Site 2 Land allocated in draft Local Plan forhousing development – no referenceof medical centre beingaccommodated.

Proposal to gift land for developmentof GP surgery

Site has room for future buildingextension

Supports delivery of GMS and PCNservices and changing model of care(including digital transformation andon line consultations )

Whilst in a central location thesite has no road frontage - notcurrently accessible

Distance from main road mayincrease costs of serviceconnections

Landlocked - negotiationsregarding access to land wouldbe required – risks associatedwith this with no guarantee ofsuccessful outcome

Financial viability - potential forincreased development costslinked to above

Delivery timeline fordevelopment

Site 3 Town Centre location

Proximity to free public car park

Close to two of the existing surgeries

Access by public transport

Premises are too small toaccommodate mergedpractices and growth inpopulation

Insufficient land on which toextend

Site owned by NHSPS butdisposal underway – site forsale (disposal supported byCCG)

Site 4 Potential to support delivery of GMSand PCN services and accommodatefuture growth

Site not allocated fordevelopment in the draft localplan – risks around planningpermission

Location not central – furthestfrom town centre of 4 options.

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3. Preferred Site

3.1. The three practices have confirmed Site 1 as their preferred site.

3.2. This site is confirmed as the Wilkes Field/ Cranbrook Engineering site – a map in appendix 1 shows the location of the site in relation to the 3 existing surgeries (<0.5 miles from each).

3.3. The practices are seeking CCG support to concentrate efforts on the preferred site in order to progress the development for the Stage 2 outline business case.

3.4. The next phase of the project will include communications and engagement with patients and stakeholders.

Appendix 1 – Map showing location of preferred site in relation to existing general practices

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West Kent CCG Front Sheet Page 202 of 202

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